Ciprofloxacin otic composition and kits and method for using same

ABSTRACT

Disclosed herein are otic product kits for administration of a sterilized formulation. In some embodiments, the otic product kit comprises: an aseptic container containing the sterilized formulation; a syring; and an administration needle connectable to the syringe, wherein the sterilized formulation comprising: from about 5.5 wt % to about 6.5 wt % multiparticulate ciprofloxacin; from about 15 wt % to about 17 wt % poloxamer 407; and water. Also disclosed herein are methods of preparing and administrating the sterilized formulation. In some embodiments, the method comprising (1) transferring the sterilized otic formulation from an aseptic container to a syringe through a preparation needle; (2) replacing the preparation needle with an administration needle; and (3) injecting the sterilized otic formulation from the syringe through the administration needle into the ear of a patient.

CROSS-REFERENCE

This application claims the benefit of U.S. Provisional Application No.62/266,537, filed Dec. 11, 2015; and U.S. Provisional Application No.62/302,724, filed on Mar. 2, 2016; both of which incorporated byreference herein in their entirety.

BACKGROUND OF THE INVENTION

Ciprofloxacin is a quinolone compound with antimicrobial activities.Some ciprofloxacin-containing pharmaceutical compositions requiresterility for specific medical applications.

SUMMARY OF THE INVENTION

Disclosed herein are otic product kits for administration of a sterlizedformulation. In some embodiments, the otic product kit comprises: anaseptic container containing the sterilized formulation; a syring; andan administration needle connectable to the syringe, wherein thesterilized formulation comprising: from about 5.5 wt % to about 6.5 wt %multiparticulate ciprofloxacin; from about 15 wt % to about 17 wt %poloxamer 407; and water.

In one refinement of the kit, the aseptic container is sealed with acap.

In one refinement of the kit, the cap comprises a metal frame having atop wall and a side wall.

In one refinement of the kit, the metal frame is made of aluminum.

In one refinement of the kit, the cap further comprises a septum securedagainst the aseptic container by the aluminum frame.

In one refinement of the kit, the administration needle is from 20 gaugeto 24 gauge.

In one refinement of the kit, the administration needle is flexible.

In one refinement of the kit, the administration needle has a blunt tip.

In one refinement of the kit, the administration needle is connectableto the syringe through luer lock.

In one refinement of the kit, the administration needle has a length offrom about 2 inches to about 3 inches.

In one refinement of the kit, the kit further comprises a preparationneedle for transferring the sterilized otic formulation from the asepticcontainer to the syringe.

In one refinement of the kit, the preparation needle is from 18 gauge to21 gauge.

In one refinement of the kit, the preparation needle is rigid.

In one refinement of the kit, the preparation needle has a sharp tip.

In one refinement of the kit, the preparation needle is connectable tothe syringe through luer lock.

In one refinement of the kit, the kit further comprises an alcohol swab.

In one refinement of the kit, the kit further comprises an ice pack.

In one refinement of the kit, the kit further comprises a drape.

In one refinement of the kit, the kit further comprises a duplicate ofeach component for bilateral administration.

In one refinement of the kit, the kit further comprises an instructionfor using the otic product kit.

In one refinement of the kit, the instruction comprises storing of theaseptic container containing the sterilized formulation below roomtemperature prior to administration.

In one refinement of the kit, the instruction comprises storing of theaseptic container containing the sterilized formulation at from about36° F. to about 46° F. prior to administration.

In one refinement of the kit, the instruction comprises storing of theaseptic container containing the sterilized formulation away from lightprior to administration.

In one refinement of the kit, the instruction further comprises shakingof the aseptic container containing the sterilized formulation prior toadministration.

In one refinement of the kit, the instruction further comprises shakingof the aseptic container containing the sterilized formulation for atleast 5 seconds prior to administration.

In one refinement of the kit, the instruction further comprises shakingof the aseptic container containing the sterilized formulation byholding the cap of the aseptic container prior to administration.

In one refinement of the kit, the instruction further comprisestransferring the sterilized formulation from the aseptic container tothe syringe prior to administration.

In one refinement of the kit, the instruction further comprisestransferring the sterilized formulation from the aseptic container tothe syringe by using the preparation needle prior to administration.

In one refinement of the kit, the instruction further comprisestransferring about 0.3 mL of the sterilized formulation from the asepticcontainer to the syringe by using the preparation needle prior toadministration.

In one refinement of the kit, the instruction further comprisesreplacing the preparation needle with the administration needle andpriming the syringe after the sterilized formulation from the asepticcontainer to the syringe.

In one refinement of the kit, the priming leave about 0.1 mL injectablevolume of the sterilized formulation in the syringe to be injectedthrough the administration needled.

In one refinement of the kit, the instruction further comprisesrepeating previous steps to prepare a second syringe for bilateraladministration.

In one refinement of the kit, the instruction further comprisesinjecting the the sterilized formulation from the syringe through theadministration needle into the ear of a patient.

In one refinement of the kit, the multiparticulate ciprofloxacin has aD90 of from about 5 μm to about 40 μm.

In one refinement of the kit, the sterilized formulation providessustained release of a therapeutically effective amount of ciprofloxacininto the ear for a period of at least 5 days after a singleadministration.

In one refinement of the kit, the sterilized otic formulation of oticproduct kit of any one of claims 1-35, where the sterilized formulationhas a pH of from about 7.0 to about 8.0.

In one refinement of the kit, the sterilized formulation has anosmolarity of from about 270 mOsm/L to about 320 mOsm/L.

Also disclosed herein are methods of preparing and administrating thesterilized formulation. In some embodiments, the method comprising (1)transferring the sterilized otic formulation from an aseptic containerto a syringe through a preparation needle; (2) replacing the preparationneedle with an administration needle; and (3) injecting the sterilizedotic formulation from the syringe through the administration needle intothe ear of a patient.

In one refinement of the method, the aseptic container is sealed with acap.

In one refinement of the method, the cap comprises a metal frame havinga top wall and a side wall.

In one refinement of the method, the metal frame is made of aluminum.

In one refinement of the method, the cap further comprises a septumsecured against the aseptic container by the aluminum frame.

In one refinement of the method, the administration needle is from 20gauge to 24 gauge.

In one refinement of the method, the administration needle is flexible.

In one refinement of the method, the administration needle has a blunttip.

In one refinement of the method, the administration needle isconnectable to the syringe through luer lock.

In one refinement of the method, the administration needle has a lengthof from about 2 inches to about 3 inches.

In one refinement of the method, the preparation needle is from 18 gaugeto 21 gauge.

In one refinement of the method, the preparation needle is rigid.

In one refinement of the method, the preparation needle has a sharp tip.

In one refinement of the method, the preparation needle is connectableto the syringe through luer lock.

In one refinement of the method, the method further comprises the stepof storing of the aseptic container containing the sterilizedformulation below room temperature prior to step (1).

In one refinement of the method, the method further comprises the stepof storing of the aseptic container containing the sterilizedformulation at from about 36° F. to about 46° F. prior to step (1).

In one refinement of the method, the aseptic container containing thesterilized formulation is stored away from light prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation for at least 5 seconds prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation by holding the cap of the aseptic container prior toadministration.

In one refinement of the method, about 0.3 mL of the sterilizedformulation is transferred from the aseptic container to the syringe byusing the preparation needle in step (1).

In one refinement of the method, the method further comprises the stepof priming the syringe between step (2) and step (3).

In one refinement of the method, the priming leave about 0.1 mLinjectable volume of the sterilized formulation in the syringe.

In one refinement of the method, the method further comprises repeatingeach step for bilateral administration.

In some embodiments of the otic product kit or method of preparing andadministrating a sterilized formulation disclosed herein, theadministration needle is not straight.

In some embodiments, the administration needle comprises at least onebend along longitudinal axis.

In some embodiments, the administration needle has one bend at aproximal portion of the administration needle.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of more than 90 degrees and lessthan 180 degrees.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of 100-170 degrees, 110-170degrees, 120-170 degrees, 130-170 degrees, or 140-160 degrees.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of 100-110 degrees, 110-120degrees, 120-130 degrees, 130-140 degrees, or 140-150 degrees, 150-160degrees, or 160-170 degrees.

In some embodiments, the administration needle comprises at least onecurved portions along longitudinal axis.

In some embodiments, the combination of geometric configuration of theneedles, in combination with one or more other technical features of thepresent disclosure, provides additional desirable or beneficialcharacteristics to the otic product kit or method of preparing andadministrating a sterilized formulation disclosed herein, including butnot limited to, convenience of administration, location of delivery,maneuverability around otic anatomy, etc.

BRIEF DESCRIPTION OF FIGURES

FIG. 1 shows X-ray characterization of ciprofloxacin anhydrous,ciprofloxacin hydrate, and an aqueous ciprofloxacin suspension formedaccording to the method disclosure herein;

FIG. 2 shows X-ray characterization of an aqueous ciprofloxacinsuspension after heat sterilization at 135° C. (without cooling down);

FIG. 3 is a photograph of the aqueous ciprofloxacin suspension in FIG. 2after cooling down, particularly illustrating the solidification of thesuspension;

FIG. 4 illustrates the anatomy of the ear;

FIG. 5 schematically illustrates sustained release of ciprofloxacin froman otic formulation formed according to the method disclosure herein;

FIG. 6 schematically illustrates non-straight administration needle insome embodiment of the otic product kit disclosed herein; and

FIG. 7 schematically illustrates the steps of using the the otic productkit disclosed herein.

DETAILED DESCRIPTION OF THE INVENTION

Provided herein are methods of making sterilized ciprofloxacincompositions. Also described herein are otic formulations containingciprofloxacin formed by the disclosed methods, and therapeutic use ofsuch otic formulation for providing sustained release of ciprofloxacininto the ear for treating various otic disorders and conditions.

Sterilization of Pharmaceutical Products

Pharmaceutical compositions sometimes need to be sterilized for specificmedical or therapeutic applications. The goal is to provide a safepharmaceutical product, relatively free of infection causingmicro-organisms. The U. S. Food and Drug Administration has providedregulatory guidance in the publication “Guidance for Industry: SterileDrug Products Produced by Aseptic Processing” available at:http://www.fda.gov/cder/guidance/5882fn1.htm, which is incorporatedherein by reference in its entirety.

As used herein, sterilization means a process used to destroy or removemicroorganisms that are present in a product or packaging. Any suitablemethod available for sterilization of objects and compositions is used.Available methods for the inactivation of microorganisms include, butare not limited to, the application of extreme heat, lethal chemicals,or gamma radiation or E-beam irradiation. In some embodiment, a processfor the preparation of an otic therapeutic formulation comprisessubjecting the formulation to a sterilization method selected from heatsterilization, chemical sterilization, radiation sterilization orfiltration sterilization. The method used depends largely upon thenature of the device or composition to be sterilized. Detaileddescriptions of many methods of sterilization are given in Chapter 40 ofRemington: The Science and Practice of Pharmacy published by Lippincott,Williams & Wilkins, and is incorporated by reference with respect tothis subject matter.

Sterilization by Heat

Many methods are available for sterilization by the application ofextreme heat. One method is through the use of a saturated steamautoclave. In some embodiments, saturated steam at a temperature of atleast 121° C. is allowed to contact the object to be sterilized. Thetransfer of heat is either directly to the microorganism, in the case ofan object to be sterilized, or indirectly to the microorganism byheating the bulk of an aqueous solution to be sterilized. This method iswidely practiced as it allows flexibility, safety and economy in thesterilization process. For example, a typical moist heat sterilizationprocess, heating to 121.5 degrees Celsius and holding for a certainduration is often used to sterilize liquid formulations and this methodis often regarded by regulatory agencies as acceptable for ensuringsterility.

Dry heat sterilization is a method which is used to kill microorganismsand perform depyrogenation at elevated temperatures. This process takesplace in an apparatus suitable for heating HEPA-filteredmicroorganism-free air to temperatures of for example 130-180° C. forthe sterilization process and to temperatures of for example 230-250° C.for the depyrogenation process. Water to reconstitute concentrated orpowdered formulations is also sterilized by autoclave.

Filtration

Filtration sterilization is a method used to remove but not destroymicroorganisms from solutions. Membrane filters are used to filterheat-sensitive solutions. Such filters are thin, strong, homogenouspolymers of mixed cellulosic esters (MCE), polyvinylidene fluoride (PVF;also known as PVDF), or polytetrafluoroethylene (PTFE) and have poresizes ranging from 0.1 to 0.22 μm. Solutions of various characteristicsare optionally filtered using different filter membranes. For example,PVF and PTFE membranes are well suited to filtering organic solventswhile aqueous solutions are filtered through PVF or MCE membranes.Filter apparatus are available for use on many scales ranging from thesingle point-of-use disposable filter attached to a syringe up tocommercial scale filters for use in manufacturing plants. The membranefilters are sterilized by autoclave or chemical sterilization.Validation of membrane filtration systems is performed followingstandardized protocols (Microbiological Evaluation of Filters forSterilizing Liquids, Vol 4, No. 3, Washington, D.C: Health IndustryManufacturers Association, 1981) and involve challenging the membranefilter with a known quantity (ca. 10⁷/cm²) of unusually smallmicroorganisms, such as Brevundimonas diminuta (ATCC 19146).

Pharmaceutical compositions are optionally sterilized by passing throughmembrane filters. Formulations comprising nanoparticles (U.S. Pat. No.6,139,870) or multilamellar vesicles (Richard et al., InternationalJournal of Pharmaceutics (2006), 312(1-2):144-50) are amenable tosterilization by filtration through 0.22 μm filters without destroyingtheir organized structure.

In some embodiments, the methods disclosed herein comprise sterilizingthe formulation (or components thereof) by means of filtrationsterilization. In another embodiment the auris-acceptable otictherapeutic agent formulation comprises a particle wherein the particleformulation is suitable for filtration sterilization. In a furtherembodiment said particle formulation comprises particles of less than300 nm in size, of less than 200 nm in size, of less than 100 nm insize. In another embodiment the auris-acceptable formulation comprises aparticle formulation wherein the sterility of the particle is ensured bysterile filtration of the precursor component solutions. In anotherembodiment the auris-acceptable formulation comprises a particleformulation wherein the sterility of the particle formulation is ensuredby low temperature sterile filtration. In a further embodiment, lowtemperature sterile filtration is carried out at a temperature between 0and 30° C., between 0 and 20° C., between 0 and 10° C., between 10 and30° C., or between 10 and 20° C.

In another embodiment is a process for the preparation of anauris-acceptable particle formulation comprising: filtering the aqueoussolution containing the particle formulation at low temperature througha sterilization filter; lyophilizing the sterile solution; andreconstituting the particle formulation with sterile water prior toadministration. In some embodiments, a formulation described herein ismanufactured as a suspension in a single vial formulation containing themicronized active pharmaceutical ingredient. A single vial formulationis prepared by aseptically mixing a sterile poloxamer solution withsterile micronized active ingredient (e.g., ciprofloxacin) andtransferring the formulation to sterile pharmaceutical containers. Insome embodiments, a single vial containing a formulation describedherein as a suspension is resuspended before dispensing and/oradministration.

In specific embodiments, filtration and/or filling procedures arecarried out at about 5° C. below the gel temperature (Tgel) of aformulation described herein and with viscosity below a theoreticalvalue of 100 cP to allow for filtration in a reasonable time using aperistaltic pump.

In another embodiment the auris-acceptable otic therapeutic agentformulation comprises a nanoparticle formulation wherein thenanoparticle formulation is suitable for filtration sterilization. In afurther embodiment the nanoparticle formulation comprises nanoparticlesof less than 300 nm in size, of less than 200 nm in size, or of lessthan 100 nm in size. In another embodiment the auris-acceptableformulation comprises a microsphere formulation wherein the sterility ofthe microsphere is ensured by sterile filtration of the precursororganic solution and aqueous solutions. In another embodiment theauris-acceptable formulation comprises a thermoreversible gelformulation wherein the sterility of the gel formulation is ensured bylow temperature sterile filtration. In a further embodiment, the lowtemperature sterile filtration occurs at a temperature between 0 and 30°C., or between 0 and 20° C., or between 0 and 10° C., or between 10 and30° C., or between 10 and 20° C. In another embodiment is a process forthe preparation of an auris-acceptable thermoreversible gel formulationcomprising: filtering the aqueous solution containing thethermoreversible gel components at low temperature through asterilization filter; lyophilizing the sterile solution; andreconstituting the thermoreversible gel formulation with sterile waterprior to administration.

In certain embodiments, the active ingredients are dissolved in asuitable vehicle (e.g. a buffer) and sterilized separately (e.g. by heattreatment, filtration, gamma or e-beam radiation). In some instances,the active ingredients are sterilized separately in a dry state. In someinstances, the active ingredients are sterilized as a suspension or as acolloidal suspension. The remaining excipients (e.g., fluid gelcomponents present in auris formulations) are sterilized in a separatestep by a suitable method (e.g. filtration and/or irradiation of acooled mixture of excipients); the two solutions that are separatelysterilized are then mixed aseptically to provide a final aurisformulation. In some instances, the final aseptic mixing is performedjust prior to administration of a formulation described herein.

In some instances, conventionally used methods of sterilization (e.g.,heat treatment (e.g., in an autoclave), gamma or e-beam irradiation,filtration) lead to irreversible degradation of polymeric components(e.g., thermosetting, gelling or mucoadhesive polymer components) and/orthe active agent in the formulation. In some instances, sterilization ofan auris formulation by filtration through membranes (e.g., 0.2 μmmembranes) is not possible if the formulation comprises thixotropicpolymers that gel during the process of filtration.

Accordingly, provided herein are methods for sterilization of aurisformulations that prevent degradation of polymeric components (e.g.,thermosetting and/or gelling and/or mucoadhesive polymer components)and/or the active agent during the process of sterilization. In someembodiments, degradation of the active agent (e.g., any therapeutic oticagent described herein) is reduced or eliminated through the use ofspecific pH ranges for buffer components and specific proportions ofgelling agents in the formulations. In some embodiments, the choice ofan appropriate gelling agent and/or thermosetting polymer allows forsterilization of formulations described herein by filtration. In someembodiments, the use of an appropriate thermosetting polymer and anappropriate copolymer (e.g., a gelling agent) in combination with aspecific pH range for the formulation allows for high temperaturesterilization of formulations described with substantially nodegradation of the therapeutic agent or the polymeric excipients. Anadvantage of the methods of sterilization provided herein is that, incertain instances, the formulations are subjected to terminalsterilization via autoclaving without any loss of the active agentand/or excipients and/or polymeric components during the sterilizationstep and are rendered substantially free of microbes and/or pyrogens.

Radiation Sterilization

One advantage of radiation sterilization is the ability to sterilizemany types of products without heat degradation or other damage. Theradiation commonly employed is beta radiation or alternatively, gammaradiation from a ⁶⁰Co source. The penetrating ability of gamma radiationallows its use in the sterilization of many product types, includingsolutions, compositions and heterogeneous mixtures. The germicidaleffects of irradiation arise from the interaction of gamma radiationwith biological macromolecules. This interaction generates chargedspecies and free radicals. Subsequent chemical reactions, such asrearrangements and cross-linking processes, result in the loss of normalfunction for these biological macromolecules. The formulations describedherein are also optionally sterilized using beta irradiation. Electronbeam (E-beam) irradiation or electron irradiation is a process whichinvolves using electrons, usually of high energy, to treat an object fora variety of purposes. This may take place under elevated temperaturesand nitrogen atmosphere. Possible uses for electron irradiation includesterilization. Electron beam processing has the ability to break thechains of DNA in living organisms, such as bacteria, resulting inmicrobial death and rendering the space they inhabit sterile. E-beamirradiation has been used for the sterilization of medical products andaseptic packaging materials for foods as well as disinfestation, theelimination of live insects from grain, tobacco, and other unprocessedbulk crops. In some embodiments, sterilization with electrons providesquick and reliable sterilization, is compatible with most materials, anddoes not require any quarantine following the processing. For somematerials and products that are sensitive to oxidative effects,radiation tolerance levels for electron beam irradiation may be higherthan for gamma exposure. This is due to the higher dose rates andshorter exposure times of e-beam irradiation which have been shown toreduce the degradative effects of oxygen.

Chemical Sterilization

Chemical sterilization methods are an alternative for products that donot withstand the extremes of heat sterilization. In this method, avariety of gases and vapors with germicidal properties, such as ethyleneoxide, chlorine dioxide, formaldehyde or ozone are used as the apoptoticagents. The germicidal activity of ethylene oxide, for example, arisesfrom its ability to serve as a reactive alkylating agent. Thus, thesterilization process requires the ethylene oxide vapors to make directcontact with the product to be sterilized.

Microorganisms

Provided herein are auris-acceptable compositions or devices thatameliorate or lessen otic disorders described herein. Further providedherein are methods comprising the administration of said oticcompositions. In some embodiments, the compositions or devices aresubstantially free of microorganisms. Acceptable bioburden or sterilitylevels are based on applicable standards that define therapeuticallyacceptable compositions, including but not limited to United StatesPharmacopeia Chapters <1111> et seq. For example, acceptable sterility(e.g., bioburden) levels include about 10 colony forming units (cfu) pergram of formulation, about 50 cfu per gram of formulation, about 100 cfuper gram of formulation, about 500 cfu per gram of formulation or about1000 cfu per gram of formulation. In some embodiments, acceptablebioburden levels or sterility for formulations include less than 10cfu/mL, less that 50 cfu/mL, less than 500 cfu/mL or less than 1000cfu/mL microbial agents. In addition, acceptable bioburden levels orsterility include the exclusion of specified objectionablemicrobiological agents. By way of example, specified objectionablemicrobiological agents include but are not limited to Escherichia coli(E. coli), Salmonella sp., Pseudomonas aeruginosa (P. aeruginosa) and/orother specific microbial agents.

Sterility of the auris-acceptable otic therapeutic agent formulation isconfirmed through a sterility assurance program in accordance withUnited States Pharmacopeia Chapters <61>, <62> and <71>. A key componentof the sterility assurance quality control, quality assurance andvalidation process is the method of sterility testing. Sterilitytesting, by way of example only, is performed by two methods. The firstis direct inoculation wherein a sample of the composition to be testedis added to growth medium and incubated for a period of time up to 21days. Turbidity of the growth medium indicates contamination. Drawbacksto this method include the small sampling size of bulk materials whichreduces sensitivity, and detection of microorganism growth based on avisual observation. An alternative method is membrane filtrationsterility testing. In this method, a volume of product is passed througha small membrane filter paper. The filter paper is then placed intomedia to promote the growth of microorganisms. This method has theadvantage of greater sensitivity as the entire bulk product is sampled.The commercially available Millipore Steritest sterility testing systemis optionally used for determinations by membrane filtration sterilitytesting. For the filtration testing of creams or ointments Steritestfilter system No. TLHVSL210 are used. For the filtration testing ofemulsions or viscous products Steritest filter system No. TLAREM210 orTDAREM210 are used. For the filtration testing of pre-filled syringesSteritest filter system No. TTHASY210 are used. For the filtrationtesting of material dispensed as an aerosol or foam Steritest filtersystem No. TTHVA210 are used. For the filtration testing of solublepowders in ampoules or vials Steritest filter system No. TTHADA210 orTTHADV210 are used.

Testing for E. coli and Salmonella includes the use of lactose brothsincubated at 30−35° C. for 24-72 hours, incubation in MacConkey and/orEMB agars for 18-24 hours, and/or the use of Rappaport medium. Testingfor the detection of P. aeruginosa includes the use of NAC agar. UnitedStates Pharmacopeia Chapter <62> further enumerates testing proceduresfor specified objectionable microorganisms.

In certain embodiments, any controlled release formulation describedherein has less than about 60 colony forming units (CFU), less thanabout 50 colony forming units, less than about 40 colony forming units,or less than about 30 colony forming units of microbial agents per gramof formulation. In certain embodiments, the otic formulations describedherein are formulated to be isotonic with the endolymph and/or theperilymph.

Endotoxins

Provided herein are otic compositions that ameliorate or lessen oticdisorders described herein. Further provided herein are methodscomprising the administration of said otic compositions. In someembodiments, the compositions or devices are substantially free ofendotoxins. An additional aspect of the sterilization process is theremoval of by-products from the killing of microorganisms (hereinafter,“Product”). The process of depyrogenation removes pyrogens from thesample. Pyrogens are endotoxins or exotoxins which induce an immuneresponse. An example of an endotoxin is the lipopolysaccharide (LPS)molecule found in the cell wall of gram-negative bacteria. Whilesterilization procedures such as autoclaving or treatment with ethyleneoxide kill the bacteria, the LPS residue induces a proinflammatoryimmune response, such as septic shock. Because the molecular size ofendotoxins can vary widely, the presence of endotoxins is expressed in“endotoxin units” (EU). One EU is equivalent to 100 picograms of E. coliLPS. Humans can develop a response to as little as 5 EU/kg of bodyweight. The bioburden (e.g., microbial limit) and/or sterility (e.g.,absence of microbes) or endotoxin level is expressed in any units asrecognized in the art. In certain embodiments, otic compositionsdescribed herein contain lower endotoxin levels (e.g. <4 EU/kg of bodyweight of a subject) when compared to conventionally acceptableendotoxin levels (e.g., 5 EU/kg of body weight of a subject). In someembodiments, the auris-acceptable otic therapeutic agent formulation hasless than about 5 EU/kg of body weight of a subject. In otherembodiments, the auris-acceptable otic therapeutic agent formulation hasless than about 4 EU/kg of body weight of a subject. In additionalembodiments, the auris-acceptable otic therapeutic agent formulation hasless than about 3 EU/kg of body weight of a subject. In additionalembodiments, the auris-acceptable otic therapeutic agent formulation hasless than about 2 EU/kg of body weight of a subject.

In some embodiments, the auris-acceptable otic therapeutic agentformulation or device has less than about 5 EU/kg of formulation. Inother embodiments, the auris-acceptable otic therapeutic agentformulation has less than about 4 EU/kg of formulation. In additionalembodiments, the auris-acceptable otic therapeutic agent formulation hasless than about 3 EU/kg of formulation. In some embodiments, theauris-acceptable otic therapeutic agent formulation has less than about5 EU/kg Product. In other embodiments, the auris-acceptable otictherapeutic agent formulation has less than about 1 EU/kg Product. Inadditional embodiments, the auris-acceptable otic therapeutic agentformulation has less than about 0.2 EU/kg Product. In some embodiments,the auris-acceptable otic therapeutic agent formulation has less thanabout 5 EU/g of unit or Product. In other embodiments, theauris-acceptable otic therapeutic agent formulation has less than about4 EU/g of unit or Product. In additional embodiments, theauris-acceptable otic therapeutic agent formulation has less than about3 EU/g of unit or Product. In some embodiments, the auris-acceptableotic therapeutic agent formulation has less than about 5 EU/mg of unitor Product. In other embodiments, the auris-acceptable otic therapeuticagent formulation has less than about 4 EU/mg of unit or Product. Inadditional embodiments, the auris-acceptable otic therapeutic agentformulation has less than about 3 EU/mg of unit or Product. In certainembodiments, otic compositions described herein contain from about 1 toabout 5 EU/mL of formulation. In certain embodiments, otic compositionsdescribed herein contain from about 2 to about 5 EU/mL of formulation,from about 3 to about 5 EU/mL of formulation, or from about 4 to about 5EU/mL of formulation.

In certain embodiments, otic compositions or devices described hereincontain lower endotoxin levels (e.g. <0.5 EU/mL of formulation) whencompared to conventionally acceptable endotoxin levels (e.g., 0.5 EU/mLof formulation). In some embodiments, the auris-acceptable otictherapeutic agent formulation or device has less than about 0.5 EU/mL offormulation. In other embodiments, the auris-acceptable otic therapeuticagent formulation has less than about 0.4 EU/mL of formulation. Inadditional embodiments, the auris-acceptable otic therapeutic agentformulation has less than about 0.2 EU/mL of formulation.

Pyrogen detection, by way of example only, is performed by severalmethods. Suitable tests for sterility include tests described in UnitedStates Pharmacopoeia (USP) <71> Sterility Tests (23rd edition, 1995).The rabbit pyrogen test and the Limulus amebocyte lysate test are bothspecified in the United States Pharmacopeia Chapters <85> and <151>(USP23/NF 18, Biological Tests, The United States PharmacopeialConvention, Rockville, Md., 1995). Alternative pyrogen assays have beendeveloped based upon the monocyte activation-cytokine assay. Uniformcell lines suitable for quality control applications have been developedand have demonstrated the ability to detect pyrogenicity in samples thathave passed the rabbit pyrogen test and the Limulus amebocyte lysatetest (Taktak et al, J. Pharm. Pharmacol. (1990, 43:578-82). In anadditional embodiment, the auris-acceptable otic therapeutic agentformulation is subject to depyrogenation. In a further embodiment, theprocess for the manufacture of the auris-acceptable otic therapeuticagent formulation comprises testing the formulation for pyrogenicity. Incertain embodiments, the formulations described herein are substantiallyfree of pyrogens.

Sterilization of Ciprofloxacin

While pharmaceutical formulations can be sterilized by heat, radiationor filtration, effective sterilization of specific pharmaceuticalcompositions often presents unique challenge(s). Those challengessometimes depend on for example, physical and chemical characteristicsof the pharmaceutical composition, physical and chemical characteristicsof the active agent, physical and chemical characteristics of thecarrier materials, physical and chemical characteristics of theauxiliary agents and/or physical and chemical characteristics of theexcipients.

For some pharmaceutical compositions comprising particulate activeagents, such as micronized active agents, filtration sterilization ofthe suspension may lead to physical separation of at least a portion ofthe particulate active agent from the rest of the composition thatpasses through the sterilization filter. Moreover, the particulateactive agent that fails to pass through the sterilization filter may notbe sufficiently sterilized.

Radiation or dry heat sterilization of bulk particulate active agent, onthe other hand, may require aseptic powder fill or formulation as a partof manufacturing process. For example, while a suspension of micronizedciprofloxacin in an aqueous carrier can be formulated by radiation ordry heat sterilization of bulk ciprofloxacin particles and asepticcompounding of sterilized ciprofloxacin particles and the sterilizedaqueous carrier, the process would require customized equipments and/orprocess design. Alternatively, the micronized ciprofloxacin can beradiation or dry heat sterilized in vials, and subsequentlyreconstituted with the aqueous carrier (as a diluent component) beforeadministration.

The present disclosure recognizes the technical effect of using a moistheat sterilization process of the ciprofloxacin bulk suspension tomanufacture a ready-to-use sterile ciprofloxacin suspension. Moreover,the present disclosure also recognizes the technical effect of particlesize and/or particle size distribution of ciprofloxacin suspension ondesirable properties such as release characteristics of the drugproduct. Furthermore, the present disclosure recognizes the technicaleffect of mixing and/or homogenization during the sterilization processon the particle size and/or particle size distribution of ciprofloxacinin suspension.

For example, a reactor with a tri-mixer system is used during heatsterilization of ciprofloxacin suspension to obtain the desired particlesize of ciprofloxacin. It is unexpectedly discovered that a 13.4% w/wsuspension of ciprofloxacin base (anhydrous) in water, when heatedat >121.5° C. for an extended period of time (e.g. 20 minutes), theliquid suspension begins to turn into a solid or semi-solid mass duringthe cool-down after heat exposure. Eventually, the liquid suspension insome examples solidifies into a dry, hard solid mixture of ciprofloxacinand water, as shown in FIG. 3. This solid mixture cannot be furtherprocessed and/or handled, or re-suspended to form the liquid suspension.

Furthermore, the present disclosure recognizes that, if theciprofloxacin suspension is mixed or homogenized aggressively when itbegins to solidify, the suspension can go through the transition andremain a liquid. If the suspension can be maintained as a liquid, asecond cycle of heat sterilization at >121.5° C. can be conducted, inwhich the ciprofloxacin suspension is less likely to solidify during thesecond cool-down. For example, in a number of large scale manufacturingruns, the mixing tank is opened up during the first cool-down when thesuspension started to solidify. As the ciprofloxacin suspension ishomogenized or mixed with large Teflon paddles by the operators, itremains a liquid suspension. On a second heat sterilization cycle, thesuspension sometimes does not solidify.

Still further, the present disclosure recognizes that that bulkciprofloxacin free base (anhydrous) can be dry heat sterilized orsterilized by Gamma or E-beam irradiation, and that sterile suspensionof ciprofloxacin in water or an aqueous carrier can be prepared byaseptically adding sterilized bulk ciprofloxacin free base (anhydrous)to sterile filtered water or aqueous carrier, followed by extensivemixing. Alternatively, ciprofloxacin free base (hydrate) can be used inthe process. While ciprofloxacin free based hydrate is not availableunder an approved Drug Master File (DMF), it can be produced from eitherHCl salt or anhydrous free base of ciprofloxacin.

In some embodiments, the method of making sterilized ciprofloxacincompositions disclosed herein includes the steps of: (a) forming anaqueous suspension comprising ciprofloxacin particles; (b) heating theaqueous suspension comprising ciprofloxacin particles at a temperaturerange of from about 100° C. to about 120° C.; and (c) allowing theaqueous suspension comprising ciprofloxacin particles to cool down.

In some embodiments, the aqueous suspension in step (a) is formed bymixing ciprofloxacin particles with water. In some embodiments, theaqueous suspension in step (a) is formed by homogenizing ciprofloxacinparticles in water.

In some embodiments, the aqueous suspension in step (a) is essentiallyfree of organic solvent.

In some embodiments, the ciprofloxacin particles in step (a) are in theform of ciprofloxacin anhydrous particles, ciprofloxacin hydrateparticles, or a combination thereof. In some embodiments, theciprofloxacin particles in step (a) are essentially in the form ofciprofloxacin hydrate particles.

In some embodiments, the ciprofloxacin particles in step (a) are presentin the aqueous suspension at a concentration of from about 4 wt % toabout 30 wt %. In some embodiments, the ciprofloxacin particles in step(a) are present in the aqueous suspension at a concentration of fromabout 4 wt % to about 20 wt %. In some embodiments, the ciprofloxacinparticles in step (a) are present in the aqueous suspension at aconcentration of from about 4 wt % to about 16 wt %.

In some embodiments, the ciprofloxacin particles in step (a) have a D90of from about 40 μm to about 80 μm. In some embodiments, theciprofloxacin particles in step (a) have a D90 of from about 45 μm toabout 75 μm. In some embodiments, the ciprofloxacin particles in step(a) have a D90 of from about 50 μm to about 70 μm. In some embodiments,the ciprofloxacin particles in step (a) have a D90 of from about 40 μmto about 80 μm.

In some embodiments, the aqueous suspension in step (b) is heated at atemperature of from about 101° C. to about 119° C. In some embodiments,the aqueous suspension in step (b) is heated at a temperature of fromabout 102° C. to about 118° C. In some embodiments, the aqueoussuspension in step (b) is heated at a temperature of from about 103° C.to about 117° C. In some embodiments, the aqueous suspension in step (b)is heated at a temperature of from about 104° C. to about 116° C. Insome embodiments, the aqueous suspension in step (b) is heated at atemperature of from about 105° C. to about 115° C.

In some embodiments, the aqueous suspension in step (b) is heated for aperiod of from about 5 minutes to about 5 hours. In some embodiments,the aqueous suspension in step (b) is heated for a period of from about10 minutes to about 5 hours. In some embodiments, the aqueous suspensionin step (b) is heated for a period of from about 20 minutes to about 5hours. In some embodiments, the aqueous suspension in step (b) is heatedfor a period of from about 30 minutes to about 5 hours. In someembodiments, the aqueous suspension in step (b) is heated for a periodof from about 40 minutes to about 4 hours. In some embodiments, theaqueous suspension in step (b) is heated for a period of from about 50minutes to about 3 hours. In some embodiments, the aqueous suspension instep (b) is heated for a period of from about 1 hour to about 2 hours.

In some embodiments, the aqueous suspension in step (b) is heated at atemperature of about 115° C. for a period of about 1 hour. In someembodiments, the aqueous suspension in step (b) is heated at atemperature of about 105° C. for a period of about 2 hour. In someembodiments, the aqueous suspension in step (b) is heated at atemperature of about 110° C. for a period of from about 1 hour to about2 hours.

In some embodiments, the aqueous suspension in step (b) is heated at aconstant temperature within the temperature range. In some embodiments,the aqueous suspension in step (b) is heated at variable temperatureswithin the temperature range.

In some embodiments, the ciprofloxacin particles in step (b) arehomogenized in the aqueous suspension when heated.

In some embodiments, the ciprofloxacin particles in step (c) areessentially in the form of ciprofloxacin hydrate particles.

In some embodiments, the ciprofloxacin particles in step (c) arehomogenized in the aqueous suspension during cooling. In someembodiments, the aqueous suspension in step (c) is allowed to cool downto from about 2° C. to about 10° C.

In some embodiments, the ciprofloxacin particles in step (c) have a D90of from about 5 μm to about 40 μm after cooling down. In someembodiments, the ciprofloxacin particles in step (c) have a D90 of fromabout 10 μm to about 35 μm after cooling down. In some embodiments, theciprofloxacin particles in step (c) have a D90 of from about 15 μm toabout 25 μm after cooling down.

It is unexpectedly discovered that if a ciprofloxacin suspension isheated sterilized at a temperature too high (e.g. >121.5° C.) or atleast initially heated at a temperature too high (e.g. initially heatedat 135° C.), the thick suspension becomes thinner. Without wishing to bebound by any particular theory, it is contemplated that ciprofloxacinfree base (anhydrous) is converted into ciprofloxacin free base(hydrate) upon mixing with water, and the hydrate form ciprofloxacinfree base is reconverted to anhydrous form during the high temperatureexposure.

It is also unexpectedly discovered that if the initial ciprofloxacinsuspension is heat sterilized at lower sterilization temperatures (e.g.100° C.-120° C.), the thickness of the suspension does not change asmuch as when the suspension is heated at the higher temperature. In someembodiments, the suspension remains thick. Furthermore, the suspensionheated at the lower temperature does not solidify during cool-down asthe suspension heated at the higher temperature. Without wishing to bebound by any particular theory, it is contemplated that thatciprofloxacin free base (anhydrous) is converted into ciprofloxacin freebase (hydrate) upon mixing with water, and the hydrate formciprofloxacin free base remains in hydrate form during the lowertemperature exposure (e.g. 100° C.-120° C.).

Furthermore, ciprofloxacin solubility significantly increases betweenroom temperature to the higher sterilization temperature (e.g. 121° C.and above). For example, it is measured to increase from 30-60 μg/mL to10-15 mg/mL. Without wishing to be bound by any particular theory, it iscontemplated that the solubility increase can contribute to thesolidification of ciprofloxacin suspension when heated at highertemperatures (e.g. 121° C. and above). For example, at highertemperature, more ciprofloxacin dissolves into the water and then whencooled back down, the ciprofloxacin precipitates/crystallizes back outof solution. It can grow onto existing crystals and lead to long needlesof solid ciprofloxacin, making the solidifying mass difficult to breakdown. The present disclosure recognizes the technical effects ofsolubility change and crystallization process on heat sterilization ofciprofloxacin suspensions.

Otic Ciprofloxacin Formulations Certain Definitions

The term “auris-acceptable” with respect to a formulation, compositionor ingredient, as used herein, includes having no persistent detrimentaleffect on the auris structure of the subject being treated. By“auris-pharmaceutically acceptable,” as used herein, refers to amaterial, such as a carrier or diluent, which does not abrogate thebiological activity or properties of the compound in reference to theauris structure, and is relatively or is reduced in toxicity to theauris structure, i.e., the material is administered to an individualwithout causing undesirable biological effects or interacting in adeleterious manner with any of the components of the composition inwhich it is contained.

As used herein, amelioration or lessening of the symptoms of aparticular otic disease, disorder or condition by administration of aparticular compound or pharmaceutical composition refers to any decreaseof severity, delay in onset, slowing of progression, or shortening ofduration, whether permanent or temporary, lasting or transient that isattributed to or associated with administration of the compound orcomposition.

“Auris interna” refers to the inner ear, including the cochlea and thevestibular labyrinth, and the round window that connects the cochleawith the middle ear.

“Auris media” refers to the middle ear, including the tympanic cavity,auditory ossicles and oval window, which connects the middle ear withthe inner ear.

“Balance disorder” refers to a disorder, illness, or condition whichcauses a subject to feel unsteady, or to have a sensation of movement.Included in this definition are dizziness, vertigo, disequilibrium, andpre-syncope. Diseases which are classified as balance disorders include,but are not limited to, Ramsay Hunt's Syndrome, Meniere's Disease, malde debarquement, benign paroxysmal positional vertigo, andlabyrinthitis.

“Blood plasma concentration” refers to the concentration of compoundsprovided herein in the plasma component of blood of a subject.

“Carrier materials” are excipients that are compatible with moist-heat,the auris structure target site and the release profile properties ofthe auris-acceptable pharmaceutical formulations. Such carrier materialsinclude, e.g., binders, suspending agents, disintegration agents,filling agents, surfactants, solubilizers, stabilizers, lubricants,wetting agents, diluents, and the like. “Auris-pharmaceuticallycompatible carrier materials” include, but are not limited to, acacia,gelatin, colloidal silicon dioxide, calcium glycerophosphate, calciumlactate, maltodextrin, glycerine, magnesium silicate,polyvinylpyrrolidone (PVP), cholesterol, cholesterol esters, sodiumcaseinate, soy lecithin, taurocholic acid, phosphatidylcholine, sodiumchloride, tricalcium phosphate, dipotassium phosphate, cellulose andcellulose conjugates, sugars sodium stearoyl lactylate, carrageenan,monoglyceride, diglyceride, pregelatinized starch, and the like.

The term “diluent” refers to chemical compounds that are used to dilutethe antimicrobial agent prior to delivery and which are compatible withthe auris structure target site.

“Dispersing agents,” and/or “viscosity modulating agents” are materialsthat control the diffusion and homogeneity of the antimicrobial agentthrough liquid media. Examples of diffusion facilitators/dispersingagents include but are not limited to hydrophilic polymers,electrolytes, Tween® 60 or 80, PEG, polyvinylpyrrolidone (PVP;commercially known as Plasdone®), and the carbohydrate-based dispersingagents such as, for example, hydroxypropyl celluloses (e.g., HPC,HPC-SL, and HPC-L), hydroxypropyl methylcelluloses (e.g., HPMC K100,HPMC K4M, HPMC K15M, and HPMC K100M), carboxymethylcellulose sodium,methylcellulose, hydroxyethylcellulo se, hydroxypropylcellulose,hydroxypropylmethylcellulose phthalate, hydroxypropylmethylcellulo seacetate stearate (HPMCAS), noncrystalline cellulose, magnesium aluminumsilicate, triethanolamine, polyvinyl alcohol (PVA), vinylpyrrolidone/vinyl acetate copolymer (S630),4-(1,1,3,3-tetramethylbutyl)-phenolpolymer with ethylene oxide andformaldehyde (also known as tyloxapol), poloxamers; and poloxamines(e.g., Tetronic908®, also known as Poloxamine908®, which is atetrafunctional block copolymer derived from sequential addition ofpropylene oxide and ethylene oxide to ethylenediamine (BASF Corporation,Parsippany, N.J.)), polyvinylpyrrolidone K12, polyvinylpyrrolidone K17,polyvinylpyrrolidone K25, or polyvinylpyrrolidone K30,polyvinylpyrrolidone/vinyl acetate copolymer (S-630), polyethyleneglycol, e.g., the polyethylene glycol has a molecular weight of about300 to about 6000, or about 3350 to about 4000, or about 7000 to about5400, sodium carboxymethylcellulose, methylcellulose, polysorbate-80,sodium alginate, gums, such as, e.g., gum tragacanth and gum acacia,guar gum, xanthans, including xanthan gum, sugars, cellulosics, such as,sodium carboxymethylcellulose, methylcellulose, sodiumcarboxymethylcellulose, polysorbate-80, sodium alginate, polyethoxylatedsorbitan monolaurate, polyethoxylated sorbitan monolaurate, povidone,carbomers, polyvinyl alcohol (PVA), alginates, chitosans andcombinations thereof. Plasticizers such as cellulose or triethylcellulose are also be used as dispersing agents. Dispersing agentsuseful in liposomal dispersions and self-emulsifying dispersions of theantimicrobial agents disclosed herein are dimyristoyl phosphatidylcholine, natural phosphatidyl choline from eggs, natural phosphatidylglycerol from eggs, cholesterol and isopropyl myristate.

“Drug absorption” or “absorption” refers to the process of movement ofthe ciprofloxacin from the localized site of administration into theear. The terms “co-administration” or the like, as used herein, aremeant to encompass administration of the ciprofloxacin to a singlepatient, and are intended to include treatment regimens in which theciprofloxacin are administered by the same or different route ofadministration or at the same or different time.

The terms “effective amount” or “therapeutically effective amount,” asused herein, refer to a sufficient amount of the ciprofloxacin beingadministered that would be expected to relieve to some extent one ormore of the symptoms of the disease or condition being treated. Forexample, the result of administration of ciprofloxacin disclosed hereinis reduction and/or alleviation of the signs, symptoms, or causes oftinnitus or balance disorders. For example, an “effective amount” fortherapeutic uses is the amount of ciprofloxacin, including a formulationas disclosed herein required to provide a decrease or amelioration indisease symptoms without undue adverse side effects. The term“therapeutically effective amount” includes, for example, aprophylactically effective amount. An “effective amount” ofciprofloxacin disclosed herein is an amount effective to achieve adesired pharmacologic effect or therapeutic improvement without undueadverse side effects. It is understood that “an effective amount” or “atherapeutically effective amount” varies, in some embodiments, fromsubject to subject, due to variation in metabolism of the compoundadministered, age, weight, general condition of the subject, thecondition being treated, the severity of the condition being treated,and the judgment of the prescribing physician. It is also understoodthat “an effective amount” in an extended-release dosing format maydiffer from “an effective amount” in an immediate release dosing formatbased upon pharmacokinetic and pharmacodynamic considerations.

The terms “enhance” or “enhancing” refers to an increase or prolongationof either the potency or duration of a desired effect of ciprofloxacin,or a diminution of any adverse symptomatology that is consequent uponthe administration of the therapeutic agent. Thus, in regard toenhancing the effect of ciprofloxacin disclosed herein, the term“enhancing” refers to the ability to increase or prolong, either inpotency or duration, the effect of other therapeutic agents that areused in combination with ciprofloxacin disclosed herein. An“enhancing-effective amount,” as used herein, refers to an amount ofciprofloxacin or other therapeutic agent which is adequate to enhancethe effect of another therapeutic agent or ciprofloxacin of the targetauris structure in a desired system. When used in a patient, amountseffective for this use will depend on the severity and course of thedisease, disorder or condition, previous therapy, the patient's healthstatus and response to the drugs, and the judgment of the treatingphysician.

“Pharmacodynamics” refers to the factors which determine the biologicresponse observed relative to the concentration of drug at the desiredsite within the auris media and/or auris interna.

“Pharmacokinetics” refers to the factors which determine the attainmentand maintenance of the appropriate concentration of drug at the desiredsite within the auris media and/or auris interna.

The term “otic intervention” means an external insult or trauma to oneor more auris structures and includes implants, otic surgery,injections, cannulations, or the like. Implants include auris-interna orauris-media medical devices, examples of which include cochlearimplants, hearing sparing devices, hearing-improvement devices,tympanostomy tubes, short electrodes, micro-prostheses or piston-likeprostheses; needles; stem cell transplants; drug delivery devices; anycell-based therapeutic; or the like. Otic surgery includes middle earsurgery, inner ear surgery, tympanostomy, cochleostomy, labyrinthotomy,mastoidectomy, stapedectomy, stapedotomy, endolymphatic sacculotomy orthe like. Injections include intratympanic injections, intracochlearinjections, injections across the round window membrane or the like.Cannulations include intratympanic, intracochlear, endolymphatic,perilymphatic or vestibular cannulations or the like.

In prophylactic applications, compositions comprising ciprofloxacindescribed herein are administered to a patient susceptible to orotherwise at risk of a particular disease, disorder or condition. Forexample, such conditions include and are not limited to otitis externa,otitis media, Ramsay Hunt syndrome, otosyphilis, AIED, Meniere'sdisease, and vestibular neuronitis. Such an amount is defined to be a“prophylactically effective amount or dose.” In this use, the preciseamounts also depend on the patient's state of health, weight, and thelike.

The term “essentially free of organic solvent” means less than 5% byweight of the active agent are degradation products of the active agent.In further embodiments, the term means less than 3% by weight of theactive agent are degradation products of the active agent. In yetfurther embodiments, the term means less than 2% by weight of the activeagent are degradation products of the active agent. In furtherembodiments, the term means less than 1% by weight of the active agentare degradation products of the active agent.

As used herein “essentially in the form of micronized powder” includes,by way of example only, greater than 70% by weight of the active agentis in the form of micronized particles of the active agent. In furtherembodiments, the term means greater than 80% by weight of the activeagent is in the form of micronized particles of the active agent. In yetfurther embodiments, the term means greater than 90% by weight of theactive agent is in the form of micronized particles of the active agent.

“Ready-to-use” refers to pharmaceutical compositions or medical productsthat can be used without the needs of further changing, modifying, oroptimizing the composition or the product prior to administration, forexample through dilution, reconstitution, further sterilization, etc.

“Stabilizers” refers to compounds such as any antioxidation agents,buffers, acids, preservatives and the like that are compatible with theenvironment of the middle or inner ear. Stabilizers include but are notlimited to agents that will do any of (1) improve the compatibility ofexcipients with a container, or a delivery system, including a syringeor a glass bottle, (2) improve the stability of a component of thecomposition, or (3) improve formulation stability.

As used herein, the term “subject” is used to mean an animal, preferablya mammal, including a human or non-human. The terms patient and subjectmay be used interchangeably.

The terms “treat,” “treating” or “treatment,” as used herein, includealleviating, abating or ameliorating a disease or condition, for exampletinnitus, symptoms, preventing additional symptoms, ameliorating orpreventing the underlying metabolic causes of symptoms, inhibiting thedisease or condition, e.g., arresting the development of the disease orcondition, relieving the disease or condition, causing regression of thedisease or condition, relieving a condition caused by the disease orcondition, or stopping the symptoms of the disease or condition eitherprophylactically and/or therapeutically.

Other objects, features, and advantages of the methods and compositionsdescribed herein will become apparent from the following detaileddescription. It should be understood, however, that the detaileddescription and the specific examples, while indicating specificembodiments, are given by way of illustration only.

Method of Formulation

In some embodiments, the methods of making sterilized ciprofloxacincompositions further include the step of: (d) combining the cooledaqueous suspension comprising ciprofloxacin particles with a sterilizedaqueous solution comprising a thermoreversible polymer to form an oticformulation.

In some embodiments, the thermoreversible polymer is apolyoxyethylene-polyoxypropylene triblock copolymer. In someembodiments, the thermoreversible polymer is poloxamer 407.

In some embodiments, the aqueous solution further comprises a bufferagent. In some embodiments, the buffer agent is tromethamine.

In some embodiments, the aqueous solution further comprises a pHadjusting agent in an amount to adjust the pH of the aqueous solution tofrom about 7.0 to about 8.0. In some embodiments, the pH adjusting agentis hydrochloric acid.

In some embodiments, the aqueous solution further comprises anosmolarity modifier. In some embodiments, the osmolarity modifier issodium chloride.

In some embodiments, the aqueous solution is sterilized throughfiltration sterilization, heat sterilization, or radiationsterilization. In some embodiments, the aqueous solution is sterilizedthrough filtration sterilization. In some embodiments, the aqueoussolution is sterilized by passing through a cold sterilization filter.

In some embodiments, the aqueous solution is allowed to cool down tofrom about 2° C. to about 10° C.

In some embodiments, the aqueous suspension and the aqueous solution arecombined under aseptic condition.

In some embodiments, the otic formulation comprises from about 5 wt % toabout 7 wt % of ciprofloxacin. In some embodiments, the otic formulationcomprises from about 5.5 wt % to about 6.5 wt % of ciprofloxacin.

In some embodiments, the otic formulation comprises from about 14 wt %to about 19 wt % of the thermoreversible polymer. In some embodiments,the otic formulation comprises from about 15 wt % to about 17 wt % ofthe thermoreversible polymer. In some embodiments, the otic formulationcomprises from about 15.5 wt % to about 16.5 wt % of thethermoreversible polymer.

In some embodiments, the otic formulation has a pH of from about 7.0 toabout 8.0.

In some embodiments, the otic formulation has an osmolarity of fromabout 270 mOsm/L to about 320 mOsm/L.

In some embodiments, the otic formulation has less than about 50 colonyforming units (cfu) of microbiological agents per gram of formulation.

In some embodiments, the otic formulation has less than about 5endotoxin units (EU) per kg of body weight of a subject.

In some embodiments, the otic formulation has a gelation temperaturebetween about 19° C. to about 42° C.

Otic Gel Formulations

Gels have been defined in various ways. For example, the United StatesPharmacopoeia defines gels as semisolid systems consisting of eithersuspensions made up of small inorganic particles or large organicmolecules interpenetrated by a liquid. Gels include a single-phase or atwo-phase system. A single-phase gel consists of organic macromoleculesdistributed uniformly throughout a liquid in such a manner that noapparent boundaries exist between the dispersed macromolecules and theliquid. Some single-phase gels are prepared from syntheticmacromolecules (e.g., carbomer) or from natural gums, (e.g.,tragacanth). In some embodiments, single-phase gels are generallyaqueous, but will also be made using alcohols and oils. Two-phase gelsconsist of a network of small discrete particles.

Gels can also be classified as being hydrophobic or hydrophilic. Incertain embodiments, the base of a hydrophobic gel consists of a liquidparaffin with polyethylene or fatty oils gelled with colloidal silica,or aluminum or zinc soaps. In contrast, the base of hydrophilic gelsusually consists of water, glycerol, or propylene glycol gelled with asuitable gelling agent (e.g., tragacanth, starch, cellulose derivatives,carboxyvinylpolymers, and magnesium-aluminum silicates). In certainembodiments, the rheology of the compositions or devices disclosedherein is pseudo plastic, plastic, thixotropic, or dilatant.

In one embodiment the enhanced viscosity auris-acceptable formulationdescribed herein is not a liquid at room temperature. In certainembodiments, the enhanced viscosity formulation is characterized by aphase transition between room temperature and body temperature(including an individual with a serious fever, e.g., up to about 42°C.). In some embodiments, the phase transition occurs at 1° C. belowbody temperature, at 2° C. below body temperature, at 3° C. below bodytemperature, at 4° C. below body temperature, at 6° C. below bodytemperature, at 8° C. below body temperature, or at 10° C. below bodytemperature. In some embodiments, the phase transition occurs at about15° C. below body temperature, at about 20° C. below body temperature orat about 25° C. below body temperature. In specific embodiments, thegelation temperature (Tgel) of a formulation described herein is about20° C., about 25° C., or about 30° C. In certain embodiments, thegelation temperature (Tgel) of a formulation described herein is about35° C., or about 40° C. In one embodiment, administration of anyformulation described herein at about body temperature reduces orinhibits vertigo associated with intratympanic administration of oticformulations. Included within the definition of body temperature is thebody temperature of a healthy individual, or an unhealthy individual,including an individual with a fever (up to ˜42° C.). In someembodiments, the pharmaceutical compositions or devices described hereinare liquids at about room temperature and are administered at or aboutroom temperature, reducing or ameliorating side effects such as, forexample, vertigo.

Polymers composed of polyoxypropylene and polyoxyethylene formthermoreversible gels when incorporated into aqueous solutions. Thesepolymers have the ability to change from the liquid state to the gelstate at temperatures close to body temperature, therefore allowinguseful formulations that are applied to the targeted auris structure(s).The liquid state-to-gel state phase transition is dependent on thepolymer concentration and the ingredients in the solution.

Poloxamer 407 is a thermoreversible polymer composed ofpolyoxyethylene-polyoxypropylene copolymers. Otherpolyoxyethylene-polyoxypropylene copolymers (i.e. poloxamers) include188 (F-68 grade), 237 (F-87 grade), 338 (F-108 grade). Aqueous solutionsof poloxamers are stable in the presence of acids, alkalis, and metalions. Poloxamer 407 is a commercially available and can be furtherpurified by suitable methods that will enhance gelation properties ofthe polymer. It contains approximately 70% ethylene oxide, whichaccounts for its hydrophilicity. It is one of the series of poloxamerABA block copolymers, whose members share the chemical formula shownbelow.

Some aqueous poloxamer solutions (e.g. poloxamer 407) transform from lowviscosity solutions to solid gels on heating to body temperature (e.g.after administration into the ear). Furthermore, poloxamer 407 has goodsolubilizing capacity, low toxicity and is, therefore, considered a goodmedium for drug delivery systems.

In an alternative embodiment, the thermogel is a PEG-PLGA-PEG triblockcopolymer (Jeong et al, Nature (1997), 388:860-2; Jeong et al, J.Control. Release (2000), 63:155-63; Jeong et al, Adv. Drug Delivery Rev.(2002), 54:37-51). The polymer exhibits sol-gel behavior over aconcentration of about 5% w/w to about 40% w/w. Depending on theproperties desired, the lactide/glycolide molar ratio in the PLGAcopolymer ranges from about 1:1 to about 20:1. The resulting copolymersare soluble in water and form a free-flowing liquid at room temperature,but form a hydrogel at body temperature. A commercially availablePEG-PLGA-PEG triblock copolymer is RESOMER RGP t50106 manufactured byBoehringer Ingelheim. This material is composed of a PGLA copolymer of50:50 poly (DL-lactide-co-glycolide) and is 10% w/w of PEG and has amolecular weight of about 6000.

ReGel® is a trade name of MacroMed Incorporated for a class of lowmolecular weight, biodegradable block copolymers having reverse thermalgelation properties as described in U.S. Pat. Nos. 6,004,573, 6,117,949,6,201,072, and 6,287,588. It also includes biodegradable polymeric drugcarriers disclosed in pending U.S. patent application Ser. Nos.09/906,041, 09/559,799 and 10/919,603. The biodegradable drug carriercomprises ABA-type or BAB-type triblock copolymers or mixtures thereof,wherein the A-blocks are relatively hydrophobic and comprisebiodegradable polyesters or poly(orthoester)s, and the B-blocks arerelatively hydrophilic and comprise polyethylene glycol (PEG), saidcopolymers having a hydrophobic content of between 50.1 to 83% by weightand a hydrophilic content of between 17 to 49.9% by weight, and anoverall block copolymer molecular weight of between 2000 and 8000Daltons. The drug carriers exhibit water solubility at temperaturesbelow normal mammalian body temperatures and undergo reversible thermalgelation to then exist as a gel at temperatures equal to physiologicalmammalian body temperatures. The biodegradable, hydrophobic A polymerblock comprises a polyester or poly(orthoester), in which the polyesteris synthesized from monomers selected from the group consisting ofD,L-lactide, D-lactide, L-lactide, D,L-lactic acid, D-lactic acid,L-lactic acid, glycolide, glycolic acid, ε-caprolactone,ε-hydroxyhexanoic acid, γ-butyrolactone, γ-hydroxybutyric acid,δ-valerolactone, δ-hydroxyvaleric acid, hydroxybutyric acids, malicacid, and copolymers thereof and having an average molecular weight ofbetween about 600 and 3000 Daltons. The hydrophilic B-block segment ispreferably polyethylene glycol (PEG) having an average molecular weightof between about 500 and 2200 Daltons.

Additional biodegradable thermoplastic polyesters include AtriGel®(provided by Atrix Laboratories, Inc.) and/or those disclosed, e.g., inU.S. Pat. Nos. 5,324,519; 4,938,763; 5,702,716; 5,744,153; and5,990,194; wherein the suitable biodegradable thermoplastic polyester isdisclosed as a thermoplastic polymer. Examples of suitable biodegradablethermoplastic polyesters include polylactides, polyglycolides,polycaprolactones, copolymers thereof, terpolymers thereof, and anycombinations thereof. In some such embodiments, the suitablebiodegradable thermoplastic polyester is a polylactide, a polyglycolide,a copolymer thereof, a terpolymer thereof, or a combination thereof. Inone embodiment, the biodegradable thermoplastic polyester is 50/50poly(DL-lactide-co-glycolide) having a carboxy terminal group; ispresent in about 30 wt. % to about 40 wt. % of the composition; and hasan average molecular weight of about 23,000 to about 45,000.Alternatively, in another embodiment, the biodegradable thermoplasticpolyester is 75/25 poly (DL-lactide-co-glycolide) without a carboxyterminal group; is present in about 40 wt. % to about 50 wt. % of thecomposition; and has an average molecular weight of about 15,000 toabout 24,000. In further or alternative embodiments, the terminal groupsof the poly(DL-lactide-co-glycolide) are either hydroxyl, carboxyl, orester depending upon the method of polymerization. Polycondensation oflactic or glycolic acid provides a polymer with terminal hydroxyl andcarboxyl groups. Ring-opening polymerization of the cyclic lactide orglycolide monomers with water, lactic acid, or glycolic acid providespolymers with the same terminal groups. However, ring-opening of thecyclic monomers with a monofunctional alcohol such as methanol, ethanol,or 1-dodecanol provides a polymer with one hydroxyl group and one esterterminal groups. Ring-opening polymerization of the cyclic monomers witha diol such as 1,6-hexanediol or polyethylene glycol provides a polymerwith only hydroxyl terminal groups.

Since the polymer systems of thermoreversible gels dissolve morecompletely at reduced temperatures, methods of solubilization includeadding the required amount of polymer to the amount of water to be usedat reduced temperatures. Generally after wetting the polymer by shaking,the mixture is capped and placed in a cold chamber or in a thermostaticcontainer at about 0-10° C. in order to dissolve the polymer. Themixture is stirred or shaken to bring about a more rapid dissolution ofthe thermoreversible gel polymer.

In one embodiment are auris-acceptable pharmaceutical gel formulationswhich do not require the use of an added viscosity enhancing agent. Suchgel formulations incorporate at least one pharmaceutically acceptablebuffer. In one aspect is a gel formulation comprising ciprofloxacin anda pharmaceutically acceptable buffer. In another embodiment, thepharmaceutically acceptable excipient or carrier is a gelling agent.

Also described herein are controlled release formulations or devicescomprising ciprofloxacin and a viscosity enhancing agent. Suitableviscosity-enhancing agents include by way of example only, gellingagents and suspending agents. In one embodiment, the enhanced viscosityformulation does not include a buffer. In other embodiments, theenhanced viscosity formulation includes a pharmaceutically acceptablebuffer. Sodium chloride or other tonicity agents are optionally used toadjust tonicity, if necessary.

By way of example only, the auris-acceptable viscosity agents includehydroxypropyl methylcellulose, hydroxyethyl cellulose,polyvinylpyrrolidone, carboxymethyl cellulose, polyvinyl alcohol, sodiumchondroitin sulfate, sodium hyaluronate. Other viscosity enhancingagents compatible with the targeted auris structure include, but are notlimited to, acacia (gum arabic), agar, aluminum magnesium silicate,sodium alginate, sodium stearate, bladderwrack, bentonite, carbomer,carrageenan, Carbopol, xanthan, cellulose, microcrystalline cellulose(MCC), ceratonia, chitin, carboxymethylated chitosan, chondrus,dextrose, furcellaran, gelatin, Ghatti gum, guar gum, hectorite,lactose, sucrose, maltodextrin, mannitol, sorbitol, honey, maize starch,wheat starch, rice starch, potato starch, gelatin, sterculia gum,xanthum gum, gum tragacanth, ethyl cellulose, ethylhydroxyethylcellulose, ethylmethyl cellulose, methyl cellulose, hydroxyethylcellulose, hydroxyethylmethyl cellulose, hydroxypropyl cellulose,poly(hydroxyethyl methacrylate), oxypolygelatin, pectin, polygeline,povidone, propylene carbonate, methyl vinyl ether/maleic anhydridecopolymer (PVM/MA), poly(methoxyethyl methacrylate),poly(methoxyethoxyethyl methacrylate), hydroxypropyl cellulose,hydroxypropylmethyl-cellulose (HPMC), sodium carboxymethyl-cellulose(CMC), silicon dioxide, polyvinylpyrrolidone (PVP: povidone), Splenda®(dextrose, maltodextrin and sucralose) or combinations thereof. Inspecific embodiments, the viscosity-enhancing excipient is a combinationof MCC and CMC. In another embodiment, the viscosity-enhancing agent isa combination of carboxymethylated chitosan, or chitin, and alginate.The combination of chitin and alginate with ciprofloxacin disclosedherein acts as a controlled release formulation, restricting thediffusion of ciprofloxacin from the formulation. Moreover, thecombination of carboxymethylated chitosan and alginate is optionallyused to assist in increasing the permeability of ciprofloxacin into theear.

In some embodiments is an enhanced viscosity formulation, comprisingfrom about 0.1 mM and about 100 mM of ciprofloxacin, a pharmaceuticallyacceptable viscosity agent, and water for injection, the concentrationof the viscosity agent in the water being sufficient to provide anenhanced viscosity formulation with a final viscosity from about 100 toabout 100,000 cP. In certain embodiments, the viscosity of the gel is inthe range from about 100 to about 50,000 cP, about 100 cP to about 1,000cP, about 500 cP to about 1500 cP, about 1000 cP to about 3000 cP, about2000 cP to about 8,000 cP, about 4,000 cP to about 50,000 cP, about10,000 cP to about 500,000 cP, about 15,000 cP to about 1,000,000 cP. Inother embodiments, when an even more viscous medium is desired, thebiocompatible gel comprises at least about 35%, at least about 45%, atleast about 55%, at least about 65%, at least about 70%, at least about75%, or even at least about 80% or so by weight of ciprofloxacin. Inhighly concentrated samples, the biocompatible enhanced viscosityformulation comprises at least about 25%, at least about 35%, at leastabout 45%, at least about 55%, at least about 65%, at least about 75%,at least about 85%, at least about 90% or at least about 95% or more byweight of ciprofloxacin.

In some embodiments, the viscosity of the gel formulations presentedherein is measured by any means described. For example, in someembodiments, an LVDV-II+CP Cone Plate Viscometer and a Cone SpindleCPE-40 is used to calculate the viscosity of the gel formulationdescribed herein. In other embodiments, a Brookfield (spindle and cup)viscometer is used to calculate the viscosity of the gel formulationdescribed herein. In some embodiments, the viscosity ranges referred toherein are measured at room temperature. In other embodiments, theviscosity ranges referred to herein are measured at body temperature(e.g., at the average body temperature of a healthy human).

In one embodiment, the pharmaceutically acceptable enhanced viscosityauris-acceptable formulation comprises ciprofloxacin and at least onegelling agent. Suitable gelling agents for use in preparation of the gelformulation include, but are not limited to, celluloses, cellulosederivatives, cellulose ethers (e.g., carboxymethylcellulose,ethylcellulose, hydroxyethylcellulose, hydroxymethylcellulose,hydroxypropylmethylcellulose, hydroxypropylcellulose, methylcellulose),guar gum, xanthan gum, locust bean gum, alginates (e.g., alginic acid),silicates, starch, tragacanth, carboxyvinyl polymers, carrageenan,paraffin, petrolatum and any combinations or mixtures thereof. In someother embodiments, hydroxypropylmethylcellulose (Methocel®) is utilizedas the gelling agent. In certain embodiments, the viscosity enhancingagents described herein are also utilized as the gelling agent for thegel formulations presented herein.

In some embodiments, the otic therapeutic agents disclosed herein aredispensed as an auris-acceptable paint. As used herein, paints (alsoknown as film formers) are solutions comprised of a solvent, a monomeror polymer, an active agent, and optionally one or morepharmaceutically-acceptable excipients. After application to a tissue,the solvent evaporates leaving behind a thin coating comprised of themonomers or polymers, and the active agent. The coating protects activeagents and maintains them in an immobilized state at the site ofapplication. This decreases the amount of active agent which may be lostand correspondingly increases the amount delivered to the subject. Byway of non-limiting example, paints include collodions (e.g. FlexibleCollodion, USP), and solutions comprising saccharide siloxane copolymersand a cross-linking agent. Collodions are ethyl ether/ethanol solutionscontaining pyroxylin (a nitrocellulose). After application, the ethylether/ethanol solution evaporates leaving behind a thin film ofpyroxylin. In solutions comprising saccharide siloxane copolymers, thesaccharide siloxane copolymers form the coating after evaporation of thesolvent initiates the cross-linking of the saccharide siloxanecopolymers. For additional disclosures regarding paints, see Remington:The Science and Practice of Pharmacy which is hereby incorporated withrespect to this subject matter. The paints contemplated for use herein,are flexible such that they do not interfere with the propagation ofpressure waves through the ear. Further, the paints may be applied as aliquid (i.e. solution, suspension, or emulsion), a semisolid (i.e. agel, foam, paste, or jelly) or an aerosol.

In some embodiments, the otic therapeutic agents disclosed herein aredispensed as a controlled-release foam. Examples of suitable foamablecarriers for use in the compositions disclosed herein include, but arenot limited to, alginate and derivatives thereof, carboxymethylcelluloseand derivatives thereof, collagen, polysaccharides, including, forexample, dextran, dextran derivatives, pectin, starch, modified starchessuch as starches having additional carboxyl and/or carboxamide groupsand/or having hydrophilic side-chains, cellulose and derivativesthereof, agar and derivatives thereof, such as agar stabilized withpolyacrylamide, polyethylene oxides, glycol methacrylates, gelatin, gumssuch as xanthum, guar, karaya, gellan, arabic, tragacanth and locustbean gum, or combinations thereof. Also suitable are the salts of theaforementioned carriers, for example, sodium alginate. The formulationoptionally further comprises a foaming agent, which promotes theformation of the foam, including a surfactant or external propellant.Examples of suitable foaming agents include cetrimide, lecithin, soaps,silicones and the like. Commercially available surfactants such asTween® are also suitable.

Other useful gel formulations are considered to fall within the scope ofthe present disclosure. For example, other commercially-availableglycerin-based gels, glycerin-derived compounds, conjugated, orcrosslinked gels, matrices, hydrogels, and polymers, as well as gelatinsand their derivatives, alginates, and alginate-based gels, and evenvarious native and synthetic hydrogel and hydrogel-derived compounds areall expected to be useful in the ciprofloxacin formulations describedherein. In some embodiments, auris-acceptable gels include, but are notlimited to, alginate hydrogels SAF®-Gel (ConvaTec, Princeton, N.J.),Duoderm® Hydroactive Gel (ConvaTec), Nu-gel® (Johnson & Johnson Medical,Arlington, Tex.); Carrasyn®(V) Acemannan Hydrogel (CarringtonLaboratories, Inc., Irving, Tex.); glycerin gels Elta® Hydrogel(Swiss-American Products, Inc., Dallas, Tex.) and K-Y® Sterile (Johnson& Johnson). In further embodiments, biodegradable biocompatible gelsalso represent compounds present in auris-acceptable formulationsdisclosed and described herein.

In some embodiments, the amount of thermoreversible polymer in anyformulation described herein is about 10%, about 15%, about 20%, about25%, about 30%, about 35% or about 40% of the total weight of theformulation. In some embodiments, the amount of thermoreversible polymerin any formulation described herein is about 10%, about 11%, about 12%,about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about19%, about 20%, about 21%, about 22%, about 23%, about 24% or about 25%of the total weight of the formulation. In some embodiments, the amountof thermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 7.5% of the total weight of the formulation.In some embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 10% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 11% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 12% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 13% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 14% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 15% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 16% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 17% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 18% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 19% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 20% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 21% of the total weight of the formulation. Insome embodiments, the amount of thermoreversible polymer (e.g.,poloxamer 407) in any formulation described herein is about 23% of thetotal weight of the formulation. In some embodiments, the amount ofthermoreversible polymer (e.g., poloxamer 407) in any formulationdescribed herein is about 25% of the total weight of the formulation. Insome embodiments, the amount of thickening agent (e.g., a gelling agent)in any formulation described herein is about 1%, about 5%, about 10%, orabout 15% of the total weight of the formulation. In some embodiments,the amount of thickening agent (e.g., a gelling agent) in anyformulation described herein is about 0.5%, about 1%, about 1.5%, about2%, about 2.5%, about 3%, about 3.5%, about 4%, about 4.5%, or about 5%of the total weight of the formulation.

In some formulations developed for administration to a mammal, and forcompositions formulated for human administration, the auris-acceptablegel comprises substantially all of the weight of the composition. Inother embodiments, the auris-acceptable gel comprises as much as about98% or about 99% of the composition by weight. This is desirous when asubstantially non-fluid, or substantially viscous formulation is needed.In a further embodiment, when slightly less viscous, or slightly morefluid auris-acceptable pharmaceutical gel formulations are desired, thebiocompatible gel portion of the formulation comprises at least about50% by weight, at least about 60% by weight, at least about 70% byweight, or even at least about 80% or 90% by weight of the compound. Allintermediate integers within these ranges are contemplated to fallwithin the scope of this disclosure, and in some alternativeembodiments, even more fluid (and consequently less viscous)auris-acceptable gel compositions are formulated, such as for example,those in which the gel or matrix component of the mixture comprises notmore than about 50% by weight, not more than about 40% by weight, notmore than about 30% by weight, or even those than comprise not more thanabout 15% or about 20% by weight of the composition.

Concentration of Ciprofloxacin

In some embodiments, the compositions described herein have aconcentration of active pharmaceutical ingredient between about 0.01% toabout 90%, between about 0.01% to about 50%, between about 0.1% to about70%, between about 0.1% to about 50%, between about 0.1% to about 40%,between about 0.1% to about 30%, between about 0.1% to about 20%,between about 0.1% to about 10%, or between about 0.1% to about 5%, ofthe active ingredient, or pharmaceutically acceptable prodrug or saltthereof, by weight of the composition. In some embodiments, thecompositions described herein have a concentration of activepharmaceutical agent, or pharmaceutically acceptable prodrug or saltthereof, between about 1% to about 50%, between about 5% to about 50%,between about 10% to about 40%, or between about 10% to about 30%, ofthe active ingredient, or pharmaceutically acceptable prodrug or saltthereof, by weight of the composition. In some embodiments, formulationsdescribed herein comprise about 70% by weight of ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by weight of theformulation. In some embodiments, formulations described herein compriseabout 60% by weight of ciprofloxacin, or pharmaceutically acceptableprodrug or salt thereof, by weight of the formulation. In someembodiments, formulations described herein comprise about 50% by weightof ciprofloxacin, or pharmaceutically acceptable prodrug or saltthereof, by weight of the formulation. In some embodiments, formulationsdescribed herein comprise about 40% by weight of ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by weight of theformulation. In some embodiments, formulations described herein compriseabout 30% by weight, or pharmaceutically acceptable prodrug or saltthereof, of ciprofloxacin by weight of the formulation. In someembodiments, formulations described herein comprise about 20% by weightof ciprofloxacin, or pharmaceutically acceptable prodrug or saltthereof, by weight of the formulation. In some embodiments, formulationsdescribed herein comprise about 15% by weight of ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by weight of theformulation. In some embodiments, formulations described herein compriseabout 10% by weight of ciprofloxacin by weight of the formulation. Insome embodiments, formulations described herein comprise about 5% byweight ciprofloxacin, or pharmaceutically acceptable prodrug or saltthereof, by weight of the formulation. In some embodiments, formulationsdescribed herein comprise about 2.5% by weight of ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by weight of theformulation. In some embodiments, formulations described herein compriseabout 1% by weight of ciprofloxacin, or pharmaceutically acceptableprodrug or salt thereof, by weight of the formulation. In someembodiments, formulations described herein comprise about 0.5% by weightof ciprofloxacin, or pharmaceutically acceptable prodrug or saltthereof, by weight of the formulation. In some embodiments, formulationsdescribed herein comprise about 0.1% by weight of ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by weight of theformulation. In some embodiments, formulations described herein compriseabout 0.01% by weight of ciprofloxacin, or pharmaceutically acceptableprodrug or salt thereof, by weight of the formulation. In someembodiments, the formulations described herein have a concentration ofactive pharmaceutical ingredient, or pharmaceutically acceptable prodrugor salt thereof, between about 0.1 to about 70 mg/mL, between about 0.5mg/mL to about 70 mg/mL, between about 0.5 mg/mL to about 50 mg/mL,between about 0.5 mg/mL to about 20 mg/mL, between about 1 mg to about70 mg/mL, between about 1 mg to about 50 mg/mL, between about 1 mg/mLand about 20 mg/mL, between about 1 mg/mL to about 10 mg/mL, or betweenabout 1 mg/mL to about 5 mg/mL, of the ciprofloxacin, orpharmaceutically acceptable prodrug or salt thereof, by volume of theformulation.

Osmolarity

In some embodiments, an otic composition or device disclosed herein isformulated to provide an ionic balance that is compatible with inner earfluids (e.g., endolymph and/or perilymph).

In certain instances, the ionic composition of the endolymph andperilymph regulate the electrochemical impulses of hair cells and thushearing. In certain instances, changes in the conduction ofelectrochemical impulses along otic hair cells results in hearing loss.In certain instances, changes in the ionic balance of the endolymph orperilymph results in complete hearing loss. In certain instances,changes in the ionic balance of the endolymph or perilymph results inpartial hearing loss. In certain instances, changes in the ionic balanceof the endolymph or perilymph results in permanent hearing loss. Incertain instances, changes in the ionic balance of the endolymph orperilymph results in temporary hearing loss.

In some embodiments, a composition or device disclosed herein isformulated in order to not disrupt the ionic balance of the endolymph.In some embodiments, a composition or device disclosed herein has anionic balance that is the same as or substantially the same as theendolymph. In some embodiments, a composition or device disclosed hereindoes not does not disrupt the ionic balance of the endolymph so as toresult in partial or complete hearing loss. In some embodiments, acomposition or device disclosed herein does not does not disrupt theionic balance of the endolymph so as to result in temporary or permanenthearing loss.

In some embodiments, a composition or device disclosed herein does notsubstantially disrupt the ionic balance of the perilymph. In someembodiments, a composition or device disclosed herein has an ionicbalance that is the same as or substantially the same as the perilymph.In some embodiments, a composition or device disclosed herein does notresult in partial or complete hearing loss as the composition or devicedoes not disrupt the ionic balance of the perilymph. In someembodiments, a composition or device disclosed herein does not result intemporary or permanent hearing loss as the composition or device doesnot disrupt the ionic balance of the perilymph.

As used herein, “practical osmolarity/osmolarity” or “deliverableosmolarity/osmolarity” means the osmolarity/osmolarity of a compositionor device as determined by measuring the osmolarity/osmolarity of theactive agent and all excipients except the gelling and/or the thickeningagent (e.g., polyoxyethylene-polyoxypropylene copolymers,carboxymethylcellulose or the like). The practical osmolarity of acomposition or device disclosed herein is measured by a suitable method,e.g., a freezing point depression method as described in Viegas et. al.,Int. J. Pharm., 1998, 160, 157-162. In some instances, the practicalosmolarity of a composition or device disclosed herein is measured byvapor pressure osmometry (e.g., vapor pressure depression method) thatallows for determination of the osmolarity of a composition or device athigher temperatures. In some instances, vapor pressure depression methodallows for determination of the osmolarity of a composition or devicecomprising a gelling agent (e.g., a thermoreversible polymer) at ahigher temperature wherein the gelling agent is in the form of a gel.

In some embodiments, the osmolarity at a target site of action is aboutthe same as the delivered osmolarity (i.e., osmolarity of materials thatcross or penetrate to the target site) of a composition or devicedescribed herein. In some embodiments, a composition or device describedherein has a deliverable osmolarity of about 150 mOsm/L to about 500mOsm/L, about 250 mOsm/L to about 500 mOsm/L, about 250 mOsm/L to about350 mOsm/L, about 280 mOsm/L to about 370 mOsm/L or about 250 mOsm/L toabout 320 mOsm/L.

The practical osmolality of an otic composition or device disclosedherein is from about 100 mOsm/kg to about 1000 mOsm/kg, from about 200mOsm/kg to about 800 mOsm/kg, from about 250 mOsm/kg to about 500mOsm/kg, or from about 250 mOsm/kg to about 320 mOsm/kg, or from about250 mOsm/kg to about 350 mOsm/kg or from about 280 mOsm/kg to about 320mOsm/kg. In some embodiments, a composition or device described hereinhas a practical osmolarity of about 100 mOsm/L to about 1000 mOsm/L,about 200 mOsm/L to about 800 mOsm/L, about 250 mOsm/L to about 500mOsm/L, about 250 mOsm/L to about 350 mOsm/L, about 250 mOsm/L to about320 mOsm/L, or about 280 mOsm/L to about 320 mOsm/L.

The main cation present in the endolymph is potassium. In addition theendolymph has a high concentration of positively charged amino acids.The main cation present in the perilymph is sodium. In certaininstances, the ionic composition of the endolymph and perilymph regulatethe electrochemical impulses of hair cells. In certain instances, anychange in the ionic balance of the endolymph or perilymph results in aloss of hearing due to changes in the conduction of electrochemicalimpulses along otic hair cells. In some embodiments, a compositiondisclosed herein does not disrupt the ionic balance of the perilymph. Insome embodiments, a composition disclosed herein has an ionic balancethat is the same as or substantially the same as the perilymph. In someembodiments, a composition disclosed herein does not disrupt the ionicbalance of the endolymph. In some embodiments, a composition disclosedherein has an ionic balance that is the same as or substantially thesame as the endolymph. In some embodiments, an otic formulationdescribed herein is formulated to provide an ionic balance that iscompatible with inner ear fluids (e.g., endolymph and/or perilymph).

In some embodiments, the deliverable osmolarity of any formulationdescribed herein is designed to be isotonic with the targeted oticstructure (e.g., endolymph, perilymph or the like). In specificembodiments, auris compositions described herein are formulated toprovide a delivered perilymph-suitable osmolarity at the target site ofaction of about 250 to about 320 mOsm/L; and preferably about 270 toabout 320 mOsm/L. In specific embodiments, auris compositions describedherein are formulated to provide a delivered perilymph-suitableosmolality at the target site of action of about 250 to about 320mOsm/kg H₂O; or an osmolality of about 270 to about 320 mOsm/kg H₂O. Inspecific embodiments, the deliverable osmolarity/osmolarity of theformulations (i.e., the osmolarity/osmolarity of the formulation in theabsence of gelling or thickening agents (e.g., thermoreversible gelpolymers) is adjusted, for example, by the use of appropriate saltconcentrations (e.g., concentration of potassium or sodium salts) or theuse of tonicity agents which renders the formulationsendolymph-compatible and/or perilymph-compatible (i.e. isotonic with theendolymph and/or perilymph) upon delivery at the target site. Theosmolarity of a formulation comprising a thermoreversible gel polymer isan unreliable measure due to the association of varying amounts of waterwith the monomeric units of the polymer. The practical osmolarity of aformulation (i.e., osmolarity in the absence of a gelling or thickeningagent (e.g. a thermoreversible gel polymer) is a reliable measure and ismeasured by any suitable method (e.g., freezing point depression method,vapor depression method). In some instances, the formulations describedherein provide a deliverable osmolarity (e.g., at a target site (e.g.,perilymph) that causes minimal disturbance to the environment of the earand causes minimum discomfort (e.g., vertigo and/or nausea) to a mammalupon administration.

In some embodiments, any formulation described herein is isotonic withthe perilymph and/or endolymph. Isotonic formulations are provided bythe addition of a tonicity agent. Suitable tonicity agents include, butare not limited to any pharmaceutically acceptable sugar, salt or anycombinations or mixtures thereof, such as, but not limited to dextrose,glycerin, mannitol, sorbitol, sodium chloride, and other electrolytes.In some embodiments, tonicity agents are non-ototoxic.

Useful auris compositions include one or more salts in an amountrequired to bring osmolarity of the composition into an acceptablerange. Such salts include those having sodium, potassium or ammoniumcations and chloride, citrate, ascorbate, borate, phosphate,bicarbonate, sulfate, thiosulfate or bisulfite anions; suitable saltsinclude sodium chloride, potassium chloride, sodium thiosulfate, sodiumbisulfite and ammonium sulfate.

The endolymph and the perilymph have a pH that is close to thephysiological pH of blood. The endolymph has a pH range of about7.2-7.9; the perilymph has a pH range of about 7.2-7.4. The in situ pHof the proximal endolymph is about 7.4 while the pH of distal endolymphis about 7.9.

In other embodiments, useful auris-acceptable ciprofloxacin formulationsalso include one or more pH adjusting agents or buffering agents toprovide an endolymph or perilymph suitable pH. Suitable pH adjustingagents or buffers include, but are not limited to acetate, bicarbonate,ammonium chloride, citrate, phosphate, pharmaceutically acceptable saltsthereof and combinations or mixtures thereof. Such pH adjusting agentsand buffers are included in an amount required to maintain pH of thecomposition between a pH of about 5 and about 9, in one embodiment a pHbetween about 6.5 to about 7.5, and in yet another embodiment at a pH ofabout 6.5, 6.6, 6.7, 6.8, 6.9, 7.0, 7.1, 7.2, 7.3, 7.4, 7.5. In oneembodiment, when one or more buffers are utilized in the formulations ofthe present disclosure, they are combined, e.g., with a pharmaceuticallyacceptable vehicle and are present in the final formulation, e.g., in anamount ranging from about 0.1% to about 20%, from about 0.5% to about10%. In certain embodiments of the present disclosure, the amount ofbuffer included in the gel formulations are an amount such that the pHof the gel formulation does not interfere with the auris media or aurisinterna's natural buffering system, or does not interfere with thenatural pH of the endolymph or perilymph. In some embodiments, fromabout 10 μM to about 200 mM concentration of a buffer is present in thegel formulation. In certain embodiments, from about a 5 mM to about a200 mM concentration of a buffer is present. In certain embodiments,from about a 20 mM to about a 100 mM concentration of a buffer ispresent. In one embodiment is a buffer such as acetate or citrate atslightly acidic pH. In one embodiment the buffer is a sodium acetatebuffer having a pH of about 4.5 to about 6.5. In one embodiment thebuffer is a sodium citrate buffer having a pH of about 5.0 to about 8.0,or about 5.5 to about 7.0.

In an alternative embodiment, the buffer used istris(hydroxymethyl)aminomethane, bicarbonate, carbonate or phosphate atslightly basic pH. In one embodiment, the buffer is a sodium bicarbonatebuffer having a pH of about 6.5 to about 8.5, or about 7.0 to about 8.0.In another embodiment the buffer is a sodium phosphate dibasic bufferhaving a pH of about 6.0 to about 9.0.

In one embodiment, when one or more buffers are utilized in theformulations of the present disclosure, they are combined, e.g., with apharmaceutically acceptable vehicle and are present in the finalformulation, e.g., in an amount ranging from about 0.1% to about 20%,from about 0.5% to about 10%. In certain embodiments of the presentdisclosure, the amount of buffer included in the gel formulations are anamount such that the pH of the gel formulation does not interfere withthe body's natural buffering system.

In one embodiment, diluents are also used to stabilize compounds becausethey can provide a more stable environment. Salts dissolved in bufferedsolutions (which also can provide pH control or maintenance) areutilized as diluents in the art, including, but not limited to aphosphate buffered saline solution.

In some embodiments, any gel formulation described herein has a pH thatallows for sterilization (e.g., by filtration or aseptic mixing or heattreatment and/or autoclaving (e.g., terminal sterilization) of a gelformulation without degradation of the ciprofloxacin or the polymerscomprising the gel. In order to reduce hydrolysis and/or degradation ofthe otic agent and/or the gel polymer during sterilization, the bufferpH is designed to maintain pH of the formulation in the 7-8 range duringthe process of sterilization (e.g., high temperature autoclaving).

In specific embodiments, any gel formulation described herein has a pHthat allows for terminal sterilization (e.g., by heat treatment and/orautoclaving) of a gel formulation without degradation of theciprofloxacin or the polymers comprising the gel. For example, in orderto reduce hydrolysis and/or degradation of the otic agent and/or the gelpolymer during autoclaving, the buffer pH is designed to maintain pH ofthe formulation in the 7-8 range at elevated temperatures. Anyappropriate buffer is used depending on the otic agent used in theformulation. In some instances, since pK_(a) of TRIS decreases astemperature increases at approximately −0.03/° C. and pK_(a) of PBSincreases as temperature increases at approximately 0.003/° C.,autoclaving at 250° F. (121° C.) results in a significant downward pHshift (i.e. more acidic) in the TRIS buffer whereas a relatively muchless upward pH shift in the PBS buffer and therefore much increasedhydrolysis and/or degradation of an otic agent in TRIS than in PBS.Degradation of an otic agent is reduced by the use of an appropriatecombination of a buffer and polymeric additives (e.g. CMC) as describedherein.

In some embodiments, a formulation pH of between about 5.0 and about9.0, between about 5.5 and about 8.5, between about 6.0 and about 7.6,between about 7 and about 7.8, between about 7.0 and about 7.6, betweenabout 7.2 and 7.6, or between about 7.2 and about 7.4 is suitable forsterilization (e.g., by filtration or aseptic mixing or heat treatmentand/or autoclaving (e.g., terminal sterilization)) of auris formulationsdescribed herein. In specific embodiments a formulation pH of about 6.0,about 6.5, about 7.0, about 7.1, about 7.2, about 7.3, about 7.4, about7.5, or about 7.6 is suitable for sterilization (e.g., by filtration oraseptic mixing or heat treatment and/or autoclaving (e.g., terminalsterilization)) of any composition described herein.

In some embodiments, the pharmaceutical formulations described hereinare stable with respect to pH over a period of any of at least about 1day, at least about 2 days, at least about 3 days, at least about 4days, at least about 5 days, at least about 6 days, at least about 1week, at least about 2 weeks, at least about 3 weeks, at least about 4weeks, at least about 5 weeks, at least about 6 weeks, at least about 7weeks, at least about 8 weeks, at least about 1 month, at least about 2months, at least about 3 months, at least about 4 months, at least about5 months, or at least about 6 months. In other embodiments, theformulations described herein are stable with respect to pH over aperiod of at least about 1 week. Also described herein are formulationsthat are stable with respect to pH over a period of at least about 1month.

Particle Size

Size reduction is used to increase surface area and/or modulateformulation dissolution properties. It is also used to maintain aconsistent average particle size distribution (PSD) (e.g.,micrometer-sized particles, nanometer-sized particles or the like) forany formulation described herein. In some embodiments, any formulationdescribed herein comprises multiparticulates, i.e., a plurality ofparticle sizes (e.g., micronized particles, nano-sized particles,non-sized particles, colloidal particles); i.e., the formulation is amultiparticulate formulation. In some embodiments, any formulationdescribed herein comprises one or more multiparticulate (e.g.,micronized) therapeutic agents. Micronization is a process of reducingthe average diameter of particles of a solid material. Micronizedparticles are from about micrometer-sized in diameter to aboutnanometer-sized in diameter. In some embodiments, the average diameterof particles in a micronized solid is from about 0.5 μm to about 500 μm.In some embodiments, the average diameter of particles in a micronizedsolid is from about 1 μm to about 200 μm. In some embodiments, theaverage diameter of particles in a micronized solid is from about 2 μmto about 100 μm. In some embodiments, the average diameter of particlesin a micronized solid is from about 3 μm to about 50 μm. In someembodiments, a particulate micronized solid comprises particle sizes ofless than about 5 microns, less than about 20 microns and/or less thanabout 100 microns. In some embodiments, the use of particulates (e.g.,micronized particles) of ciprofloxacin allows for extended and/orsustained release of ciprofloxacin from any formulation described hereincompared to a formulation comprising non-multiparticulate ciprofloxacin.In some instances, formulations containing multiparticulate (e.g.micronized) ciprofloxacin are ejected from a 1 mL syringe adapted with a27G needle without any plugging or clogging.

In some instances, any particle in any formulation described herein is acoated particle (e.g., a coated micronized particle, nano-particle)and/or a microsphere and/or a liposomal particle. Particle sizereduction techniques include, by way of example, grinding, milling(e.g., air-attrition milling (jet milling), ball milling), coacervation,complex coacervation, high pressure homogenization, spray drying and/orsupercritical fluid crystallization. In some instances, particles aresized by mechanical impact (e.g., by hammer mills, ball mill and/or pinmills). In some instances, particles are sized via fluid energy (e.g.,by spiral jet mills, loop jet mills, and/or fluidized bed jet mills). Insome embodiments formulations described herein comprise crystallineparticles and/or isotropic particles. In some embodiments, formulationsdescribed herein comprise amorphous particles and/or anisotropicparticles. In some embodiments, formulations described herein comprisetherapeutic agent particles wherein the therapeutic agent is a freebase, or a salt, or a prodrug of a therapeutic agent, or any combinationthereof.

The multiparticulates and/or micronized ciprofloxacin formulationsdescribed herein are delivered to an auris structure (e.g., middle ear)by means of any type of matrix including solid, liquid or gel matrices.In some embodiments, the multiparticulates and/or micronizedciprofloxacin described herein are delivered to an auris structure(e.g., middle ear) by means of any type of matrix including solid,liquid or gel matrices via intratympanic injection.

Therapeutic Use of Otic Ciprofloxacin Formulations

Anatomy of the Ear

As shown in FIG. 4, the outer ear is the external portion of the organand is composed of the pinna (auricle), the auditory canal (externalauditory meatus) and the outward facing portion of the tympanicmembrane, also known as the ear drum. The pinna, which is the fleshypart of the external ear that is visible on the side of the head,collects sound waves and directs them toward the auditory canal. Thus,the function of the outer ear, in part, is to collect and direct soundwaves towards the tympanic membrane and the middle ear.

The middle ear is an air-filled cavity, called the tympanic cavity,behind the tympanic membrane. The tympanic membrane, also known as theear drum, is a thin membrane that separates the external ear from themiddle ear. The middle ear lies within the temporal bone, and includeswithin this space the three ear bones (auditory ossicles): the malleus,the incus and the stapes. The auditory ossicles are linked together viatiny ligaments, which form a bridge across the space of the tympaniccavity. The malleus, which is attached to the tympanic membrane at oneend, is linked to the incus at its anterior end, which in turn is linkedto the stapes. The stapes is attached to the oval window, one of twowindows located within the tympanic cavity. A fibrous tissue layer,known as the annular ligament connects the stapes to the oval window.Sound waves from the outer ear first cause the tympanic membrane tovibrate. The vibration is transmitted across to the cochlea through theauditory ossicles and oval window, which transfers the motion to thefluids in the auris interna. Thus, the auditory ossicles are arranged toprovide a mechanical linkage between the tympanic membrane and the ovalwindow of the fluid-filled auris interna, where sound is transformed andtransduced to the auris interna for further processing. Stiffness,rigidity or loss of movement of the auditory ossicles, tympanic membraneor oval window leads to hearing loss, e.g. otosclerosis, or rigidity ofthe stapes bone.

The tympanic cavity also connects to the throat via the eustachian tube.The eustachian tube provides the ability to equalize the pressurebetween the outside air and the middle ear cavity. The round window, acomponent of the auris interna but which is also accessible within thetympanic cavity, opens into the cochlea of the auris interna. The roundwindow is covered by round window membrane, which consists of threelayers: an external or mucous layer, an intermediate or fibrous layer,and an internal membrane, which communicates directly with the cochlearfluid. The round window, therefore, has direct communication with theauris interna via the internal membrane.

Movements in the oval and round window are interconnected, i.e. as thestapes bone transmits movement from the tympanic membrane to the ovalwindow to move inward against the auris interna fluid, the round window(round window membrane) is correspondingly pushed out and away from thecochlear fluid. This movement of the round window allows movement offluid within the cochlea, which leads in turn to movement of thecochlear inner hair cells, allowing hearing signals to be transduced.Stiffness and rigidity in round window membrane leads to hearing lossbecause of the lack of ability of movement in the cochlear fluid. Recentstudies have focused on implanting mechanical transducers onto the roundwindow, which bypasses the normal conductive pathway through the ovalwindow and provides amplified input into the cochlear chamber.

Auditory signal transduction takes place in the auris interna. Thefluid-filled auris interna, or inner ear, consists of two majorcomponents: the cochlear and the vestibular apparatus. The auris internais located in part within the osseous or bony labyrinth, an intricateseries of passages in the temporal bone of the skull. The vestibularapparatus is the organ of balance and consists of the threesemi-circular canals and the vestibule. The three semi-circular canalsare arranged relative to each other such that movement of the head alongthe three orthogonal planes in space can be detected by the movement ofthe fluid and subsequent signal processing by the sensory organs of thesemi-circular canals, called the crista ampullaris. The cristaampullaris contains hair cells and supporting cells, and is covered by adome-shaped gelatinous mass called the cupula. The hairs of the haircells are embedded in the cupula. The semi-circular canals detectdynamic equilibrium, the equilibrium of rotational or angular movements.

When the head turns rapidly, the semicircular canals move with the head,but endolymph fluid located in the membranous semi-circular canals tendsto remain stationary. The endolymph fluid pushes against the cupula,which tilts to one side. As the cupula tilts, it bends some of the hairson the hair cells of the crista ampullaris, which triggers a sensoryimpulse. Because each semicircular canal is located in a differentplane, the corresponding crista ampullaris of each semi-circular canalresponds differently to the same movement of the head. This creates amosaic of impulses that are transmitted to the central nervous system onthe vestibular branch of the vestibulocochlear nerve. The centralnervous system interprets this information and initiates the appropriateresponses to maintain balance. Of importance in the central nervoussystem is the cerebellum, which mediates the sense of balance andequilibrium.

The vestibule is the central portion of the auris interna and containsmechanoreceptors bearing hair cells that ascertain static equilibrium,or the position of the head relative to gravity. Static equilibriumplays a role when the head is motionless or moving in a straight line.The membranous labyrinth in the vestibule is divided into two sac-likestructures, the utricle and the saccule. Each structure in turn containsa small structure called a macula, which is responsible for maintenanceof static equilibrium. The macula consists of sensory hair cells, whichare embedded in a gelatinous mass (similar to the cupula) that coversthe macula. Grains of calcium carbonate, called otoliths, are embeddedon the surface of the gelatinous layer.

When the head is in an upright position, the hairs are straight alongthe macula. When the head tilts, the gelatinous mass and otoliths tiltscorrespondingly, bending some of the hairs on the hair cells of themacula. This bending action initiates a signal impulse to the centralnervous system, which travels via the vestibular branch of thevestibulocochlear nerve, which in turn relays motor impulses to theappropriate muscles to maintain balance.

The cochlea is the portion of the auris interna related to hearing. Thecochlea is a tapered tube-like structure which is coiled into a shaperesembling a snail. The inside of the cochlea is divided into threeregions, which is further defined by the position of the vestibularmembrane and the basilar membrane. The portion above the vestibularmembrane is the scala vestibuli, which extends from the oval window tothe apex of the cochlea and contains perilymph fluid, an aqueous liquidlow in potassium and high in sodium content. The basilar membranedefines the scala tympani region, which extends from the apex of thecochlea to the round window and also contains perilymph. The basilarmembrane contains thousands of stiff fibers, which gradually increase inlength from the round window to the apex of the cochlea. The fibers ofthe basement membrane vibrate when activated by sound. In between thescala vestibuli and the scala tympani is the cochlear duct, which endsas a closed sac at the apex of the cochlea. The cochlear duct containsendolymph fluid, which is similar to cerebrospinal fluid and is high inpotassium.

The organ of Corti, the sensory organ for hearing, is located on thebasilar membrane and extends upward into the cochlear duct. The organ ofCorti contains hair cells, which have hairlike projections that extendfrom their free surface, and contacts a gelatinous surface called thetectorial membrane. Although hair cells have no axons, they aresurrounded by sensory nerve fibers that form the cochlear branch of thevestibulocochlear nerve (cranial nerve VIII).

As discussed, the oval window, also known as the elliptical windowcommunicates with the stapes to relay sound waves that vibrate from thetympanic membrane. Vibrations transferred to the oval window increasespressure inside the fluid-filled cochlea via the perilymph and scalavestibuli/scala tympani, which in turn causes the round window membraneto expand in response. The concerted inward pressing of the ovalwindow/outward expansion of the round window allows for the movement offluid within the cochlea without a change of intra-cochlear pressure.However, as vibrations travel through the perilymph in the scalavestibuli, they create corresponding oscillations in the vestibularmembrane. These corresponding oscillations travel through the endolymphof the cochlear duct, and transfer to the basilar membrane. When thebasilar membrane oscillates, or moves up and down, the organ of Cortimoves along with it. The hair cell receptors in the Organ of Corti thenmove against the tectorial membrane, causing a mechanical deformation inthe tectorial membrane. This mechanical deformation initiates the nerveimpulse which travels via the vestibulocochlear nerve to the centralnervous system, mechanically transmitting the sound wave received intosignals that are subsequently processed by the central nervous system.

Otic Disorders or Conditions

Otitis externa (OE), also referred to as swimmer's ear, is aninflammation of the external ear and/or ear canal. OE is primarilycaused by bacteria (e.g., Pseudomonas aeruginosa and Staphylococcusaureus) or fungi (e.g., Candida albicans and Aspergillus) in the outerear, which establish infection following damage to the skin of the earcanal. Symptoms of OE include otalgia, swelling, and otorrhea. If thecondition progresses significantly, OE may cause temporary conductivehearing loss as a result of the swelling and discharge. Treatment of OEinvolves eliminating the aggravating pathogen from the ear canal andreducing inflammation, which is usually accomplished by administeringcombinations of antimicrobial agents, e.g., ciprofloxacin, withanti-inflammatory agents, e.g., steroids.

Otitis media (OM) is an inflammation of the middle ear. Bacterialinfection accounts for a large percentage of OM cases, with more than40% of cases attributed to Streptococcus pneumoniae infection. However,viruses, as well as other microbes, may account for OM conditions.Because OM can be caused by a virus, bacteria or both, ciprofloxacin isused to eliminate the underlying pathogen.

Syphilis is a venereal disease, caused by the spirochete Treponemapallidum, which may result in otic disorders, particularlycochleovestibular disorders, due to membranous labyrinthitis, andsecondarily meningitis. Both acquired and congenital syphilis can causeotic disorders. Symptoms of cochleovestibular disorders resulting fromsyphilis are often similar to those of other otic disorders, such asAIED and Meniere's disease, and include tinnitus, deafness, vertigo,malaise, sore throat, headaches, and skin rashes.

Treatment of otosyphilis (syphilis presenting otic symptoms) typicallyincludes a combination of steroids and antibacterial agents. Suchtreatments may be effective in eradicating the spirochete organism whilereducing inflammation. However, Treponemas may remain in the cochlearand vestibular endolymph even after eradication from other sites in thebody. Accordingly, long term treatment with penicillins may be requiredto achieve complete eradication of the spirochete organism from theendolymph fluid.

Systemic antimicrobial administration for the treatment of oticdisorders, e.g., OE, OM and otosyphilis, may create a potentialinequality in drug concentration with higher circulating levels in theserum, and lower levels in the target auris organ structures. As aresult, fairly large amounts of drug are required to overcome thisinequality in order to deliver sufficient, therapeutically effectivequantities to the ear. Further, bioavailability is often decreased dueto metabolism of the drug by the liver. In addition, systemic drugadministration may increase the likelihood of systemic toxicities andadverse side effects as a result of the high serum amounts required toeffectuate sufficient local delivery to the target site. Systemictoxicities may also occur as a result of liver breakdown and processingof the therapeutic agents, forming toxic metabolites that effectivelyerase any benefit attained from the administered therapeutic.

To overcome the toxic and attendant undesired side effects of systemicdelivery of ciprofloxacin (which are generally understood to be toxic tocells), disclosed herein are methods and compositions for local deliveryof ciprofloxacin to auris media and/or auris interna structures. Infurther or alternative embodiments, the auris controlled-releaseformulations are capable of being administered via intratympanicinjection. In some embodiments, the auris controlled release formulationis applied via syringe and needle, wherein the needle is insertedthrough the tympanic membrane and guided to the area of target site inthe middle ear.

Because of the localized targeting of the ciprofloxacin formulations andcompositions, as well as the biological blood barrier present in theauris structure, the risk of adverse effects will be reduced as a resultof treatment with previously characterized toxic or ineffectiveciprofloxacin. Localized administration of antimicrobial agentcompositions reduces the risk of development of resistance toantibiotics compared to the risk for development of antibioticresistance when an antibiotic is administered systemically. Thecompositions described herein are effective for recurring otic diseasesor conditions including, for example, recurring ear infections inchildren without the need for changing treatment regimens (e.g., inresponse to development of antibiotic resistance). Accordingly, alsocontemplated within the scope of the embodiments herein is the use ofciprofloxacin in the treatment of otic diseases or conditions includingotitis externa, otitis media, Ramsay Hunt syndrome, otosyphilis, AIED,Meniere's disease, and vestibular neuronitis, including therapeuticagents that have been previously rejected by practitioners because ofadverse effects or ineffectiveness of the ciprofloxacin.

Also included within the embodiments disclosed herein is the use ofadditional auris media and/or auris interna-acceptable agents incombination with the ciprofloxacin formulations and compositionsdisclosed herein. When used, such agents assist in the treatment ofhearing or equilibrium loss or dysfunction resulting from an autoimmunedisorder, including vertigo, tinnitus, hearing loss, balance disorders,infections, inflammatory response or combinations thereof. Accordingly,agents that ameliorate or reduce the effects of vertigo, tinnitus,hearing loss, balance disorders, infections, inflammatory response orcombinations thereof are also contemplated to be used in combinationwith the ciprofloxacin formulations described herein.

In some embodiments, the composition further comprises ciprofloxacin asan immediate release agent wherein the immediate release ciprofloxacinis the same agent as the controlled-release agent, a differentantimicrobial agent, an additional therapeutic agent, or a combinationthereof. In some embodiments, the composition further comprises anadditional therapeutic agent, including an additional antimicrobialagent, an anti-inflammatory agent, a corticosteroid, a cytotoxic agent,an anti-TNF agent, a collagen, a gamma-globulin, an interferon, aplatelet activator factor antagonist, a nitric oxide synthase inhibitor,or combinations thereof. In another aspect, the additional therapeuticagent is an immediate release or a controlled release agent.

In some embodiments, the additional therapeutic agent is an immediaterelease agent. In some embodiments, the additional therapeutic agent isa controlled release agent.

Accordingly, provided herein are controlled release ciprofloxacinformulations and compositions to locally treat auris media and/or aurisinterna structures, thereby avoiding side effects as a result ofsystemic administration of ciprofloxacin. The locally appliedciprofloxacin formulations and compositions are compatible with aurismedia and/or auris interna structures, and are administered eitherdirectly to the desired auris media and/or auris interna structure, e.g.the tympanic cavity. By specifically targeting the auris media or aurisinterna structures, adverse side effects as a result of systemictreatment are avoided. Moreover, by providing a controlled releaseciprofloxacin formulation or composition to treat otic disorders, aconstant and/or extended source of ciprofloxacin is provided to theindividual or patient suffering from an otic disorder, reducing oreliminating the variability of treatment.

Intratympanic injection of therapeutic agents also includes thetechnique of injecting a therapeutic agent behind the tympanic membraneinto the auris media and/or auris interna.

However, intra-tympanic injections create several unrecognized problemsnot addressed by currently available treatment regimens, such aschanging the osmolarity and pH of the perilymph and endolymph, andintroducing pathogens and endotoxins that directly or indirectly damageear structures. One of the reasons the art may not have recognized theseproblems is that there are no approved intra-tympanic compositions: themiddle and inner ear provides sui generis formulation challenges. Thus,compositions developed for other parts of the body have little to norelevance for an intra-tympanic composition.

There is no guidance in the prior art regarding requirements (e.g.,level of sterility, pH, osmolarity) for otic formulations that aresuitable for administration to humans. There is wide anatomicaldisparity between the ears of animals across species. A consequence ofthe inter-species differences in auditory structures is that animalmodels of ear disease are often unreliable as a tool for testingtherapeutics that are being developed for clinical approval.

Provided herein are otic formulations that meet stringent criteria forpH, osmolarity, ionic balance, sterility, endotoxin and/or pyrogenlevels. The auris compositions described herein are compatible with themicroenvironment of the ear (e.g., the middle ear) and are suitable foradministration to humans. In some embodiments, the formulationsdescribed herein comprise dyes and aid visualization of the administeredcompositions obviating the need for invasive procedures (e.g., removalof perilymph) during preclinical and/or clinical development ofintratympanic therapeutics.

Provided herein are controlled release ciprofloxacin formulations andcompositions to locally treat targeted auris structures, therebyavoiding side effects as a result of systemic administration of theciprofloxacin formulations and compositions. The locally appliedciprofloxacin formulations and compositions and devices are compatiblewith the targeted auris structures, and administered either directly tothe desired targeted auris structure, e.g. the cochlear region, thetympanic cavity or the external ear. By specifically targeting an aurisstructure, adverse side effects as a result of systemic treatment areavoided. Moreover, clinical studies have shown the benefit of havinglong term exposure of drug to the perilymph of the cochlea, for examplewith improved clinical efficacy of sudden hearing loss when thetherapeutic agent is given on multiple occasions. Thus, by providing acontrolled release ciprofloxacin formulation or composition to treatotic disorders, a constant, and/or extended source of ciprofloxacin isprovided to the individual or patient suffering from an otic disorder,reducing or eliminating variabilities in treatment. Accordingly, oneembodiment disclosed herein is to provide a composition that enablesciprofloxacin to be released in therapeutically effective doses eitherat variable or constant rates such as to ensure a continuous release ofthe at least one agent. In some embodiments, the ciprofloxacin disclosedherein are administered as an immediate release formulation orcomposition. In other embodiments, the ciprofloxacin are administered asa sustained release formulation, released either continuously, variablyor in a pulsatile manner, or variants thereof. In still otherembodiments, ciprofloxacin formulation is administered as both animmediate release and sustained release formulation, released eithercontinuously, variably or in a pulsatile manner, or variants thereof.The release is optionally dependent on environmental or physiologicalconditions, for example, the external ionic environment (see, e.g. Oros®release system, Johnson & Johnson).

In addition, the ciprofloxacin compositions or formulations or devicesincluded herein also include carriers, adjuvants, such as preserving,stabilizing, wetting or emulsifying agents, solution promoters, saltsfor regulating the osmotic pressure, and/or buffers. Such carriers,adjuvants, and other excipients will be compatible with the environmentin the targeted auris structure(s). Accordingly, specificallycontemplated for the compositions and devices described herein arecarriers, adjuvants and excipients that lack ototoxicity or areminimally ototoxic in order to allow effective treatment of the oticdisorders contemplated herein with minimal side effects in the targetedregions or areas.

Intratympanic injection of compositions or devices creates severaladditional problems that must also be addressed before the compositionor device can be administered. For example, there are many excipientsthat are ototoxic. While these excipients can be used when formulatingan active agent for delivery by another method (e.g., topical), theiruse should be limited, reduced or eliminated when formulating a deliverydevice to be administered to the ear due to their ototoxic effects.

By way of non-limiting example, the use of the following commonly usedsolvents should be limited, reduced or eliminated when formulatingagents for administration to the ear: alcohols, propylene glycol, andcyclohexane. Thus, in some embodiments, a device disclosed herein isfree or substantially free of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 50 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 25 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 20 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 10 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 5 ppm of each of alcohols, propylene glycol, andcyclohexane. In some embodiments, a device disclosed herein comprisesless than about 1 ppm of each of alcohols, propylene glycol, andcyclohexane.

Further, by way of non-limiting example, the use of the followingcommonly utilized preservatives should be limited, reduced or eliminatedwhen formulating agents for administration to the ear: Benzethoniumchloride, Benzalkonium chloride, and Thiomersal. Thus, in someembodiments, a device disclosed herein is free or substantially free ofbenzethonium chloride, benzalkonium chloride, and thiomersal. In someembodiments, a device disclosed herein comprises less than about 50 ppmof each of benzethonium chloride, benzalkonium chloride, and thiomersal.In some embodiments, a device disclosed herein comprises less than about25 ppm of each of benzethonium chloride, benzalkonium chloride, andthiomersal. In some embodiments, a device disclosed herein comprisesless than about 20 ppm of each of benzethonium chloride, benzalkoniumchloride, and thiomersal. In some embodiments, a device disclosed hereincomprises less than about 10 ppm of each of benzethonium chloride,benzalkonium chloride, and thiomersal. In some embodiments, a devicedisclosed herein comprises less than about 5 ppm of each of benzethoniumchloride, benzalkonium chloride, and thiomersal. In some embodiments, adevice disclosed herein comprises less than about 1 ppm of each ofbenzethonium chloride, benzalkonium chloride, and thiomersal.

Certain antiseptics used to disinfect components of therapeuticpreparations (or the devices utilized to administer the preparations)should be limited, reduced, or eliminated in otic preparations. Forexample, acetic acid, iodine, and merbromin are all known to beototoxic. Additionally, chlorhexidene, a commonly used antiseptic,should be limited, reduced or eliminated to disinfect any component ofan otic preparation (including devices used to administer thepreparation) as it is highly ototoxic in minute concentrations (e.g.,0.05%). Thus, in some embodiments, a device disclosed herein is free orsubstantially free of acetic acid, iodine, merbromin, and chlorhexidene.In some embodiments, a device disclosed herein comprises less than about50 ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 25ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 20ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 10ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 5ppm of each of acetic acid, iodine, merbromin, and chlorhexidene. Insome embodiments, a device disclosed herein comprises less than about 1ppm of each of acetic acid, iodine, merbromin, and chlorhexidene.

Further, otic preparations require particularly low concentrations ofseveral potentially-common contaminants that are known to be ototoxic.Other dosage forms, while seeking to limit the contaminationattributable to these compounds, do not require the stringentprecautions that otic preparations require. For example, the followingcontaminants should be absent or nearly absent from otic preparations:arsenic, lead, mercury, and tin. Thus, in some embodiments, a devicedisclosed herein is free or substantially free of arsenic, lead,mercury, and tin. In some embodiments, a device disclosed hereincomprises less than about 50 ppm of each of arsenic, lead, mercury, andtin. In some embodiments, a device disclosed herein comprises less thanabout 25 ppm of each of arsenic, lead, mercury, and tin. In someembodiments, a device disclosed herein comprises less than about 20 ppmof each of arsenic, lead, mercury, and tin. In some embodiments, adevice disclosed herein comprises less than about 10 ppm of each ofarsenic, lead, mercury, and tin. In some embodiments, a device disclosedherein comprises less than about 5 ppm of each of arsenic, lead,mercury, and tin. In some embodiments, a device disclosed hereincomprises less than about 1 ppm of each of arsenic, lead, mercury, andtin.

To prevent ototoxicity, ciprofloxacin compositions or formulations ordevices disclosed herein are optionally targeted to distinct regions ofthe targeted auris structures, including but not limited to the tympaniccavity.

Otic Surgery and Implants

In some embodiments, the pharmaceutical formulations, compositions ordevices described herein are used in combination with (e.g.,implantation, short-term use, long-term use, or removal of) implants(e.g., cochlear implants). As used herein, implants includeauris-interna or auris-media medical devices, examples of which includecochlear implants, hearing sparing devices, hearing-improvement devices,short electrodes, tympanostomy tubes, micro-prostheses or piston-likeprostheses; needles; stem cell transplants; drug delivery devices; anycell-based therapeutic; or the like. In some instances, the implants areused in conjunction with a patient experiencing hearing loss. In someinstances, the hearing loss is present at birth. In some instances, thehearing loss is associated with conditions such as AIED, bacterialmeningitis or the like that lead to osteoneogenesis and/or nerve damagewith rapid obliteration of cochlear structures and profound hearingloss.

In some instances, an implant is an immune cell or a stem celltransplant in the ear. In some instances, an implant is a smallelectronic device that has an external portion placed behind the ear,and a second portion that is surgically placed under the skin that helpsprovide a sense of sound to a person who is profoundly deaf or severelyhard-of-hearing. By way of example, such cochlear medical deviceimplants bypass damaged portions of the ear and directly stimulate theauditory nerve. In some instances cochlear implants are used in singlesided deafness. In some instances cochlear implants are used fordeafness in both ears.

In some embodiments, administration of ciprofloxacin compositiondescribed herein in combination with an otic intervention (e.g., anintratympanic injection, a stapedectomy, a tympanostomy, a medicaldevice implant or a cell-based transplant) delays or prevents collateraldamage to auris structures, e.g., irritation, inflammation and/orinfection, caused by the external otic intervention (e.g., installationof an external device and/or cells in the ear). In some embodiments,administration of ciprofloxacin composition described herein incombination with an implant allows for a more effective restoration ofhearing loss compared to an implant alone.

In some embodiments, administration of ciprofloxacin compositiondescribed herein reduces damage to cochlear structures caused byunderlying conditions (e.g., bacterial meningitis, autoimmune eardisease (AIED)) allowing for successful cochlear device implantation. Insome embodiments, administration of a composition or device describedherein, in conjunction with otic surgery, medical device implantationand/or cell transplantation, reduces or prevents cell damage and/orinflammation associated with otic surgery, medical device implantationand/or cell transplantation.

In some embodiments, administration of ciprofloxacin compositiondescribed herein (e.g., a composition or device comprising acorticosteriod) in conjunction with a cochlear implant or stem celltransplant has a trophic effect (e.g., promotes healthy growth of cellsand/or healing of tissue in the area of an implant or transplant). Insome embodiments, a trophic effect is desirable during otic surgery orduring intratympanic injection procedures. In some embodiments, atrophic effect is desirable after installation of a medical device orafter a cell transplant. In some embodiments, a medical device is coatedwith a composition described herein prior to implantation in the ear.

In some embodiments, administration of an anti-inflammatory orimmunosuppressant composition (e.g., a composition comprising animmunosuppresant such as a corticosteroid) reduces inflammation and/orinfections associated with otic surgery, implantation of a medicaldevice or a cell transplant. In some instances, perfusion of a surgicalarea with ciprofloxacin formulation described herein and/or ananti-inflammatory formulation described herein reduces or eliminatespost-surgical and/or post-implantation complications (e.g.,inflammation, cell damage, infection, osteoneogenesis or the like). Insome instances, perfusion of a surgical area with a formulationdescribed herein reduces post-surgery or post-implantation recuperationtime.

In one aspect, the formulations described herein, and modes ofadministration thereof, are applicable to methods of direct perfusion ofthe middle ear compartments. Thus, the formulations described herein areuseful in combination with otic interventions. In some embodiments, anotic intervention is an implantation procedure (e.g., implantation of ahearing device in the cochlea). In some embodiments, an oticintervention is a surgical procedure including, by way of non-limitingexamples, cochleostomy, labyrinthotomy, mastoidectomy, stapedectomy,stapedotomy, tympanostomy, endolymphatic sacculotomy or the like. Insome embodiments, the middle ear compartments are perfused with aformulation described herein prior to otic intervention, during oticintervention, or after otic intervention, or a combination thereof.

In some embodiments, when perfusion is carried out in combination withotic intervention, the ciprofloxacin compositions are immediate releasecompositions (e.g., a composition comprising ciprofloxacin). In some ofsuch embodiments, the immediate release formulations described hereinare non-thickened compositions and are substantially free of extendedrelease components (e.g., gelling components such aspolyoxyethylene-polyoxypropylene copolymers). In some of suchembodiments, the compositions contain less than 5% of the extendedrelease components (e.g., gelling components such aspolyoxyethylene-polyoxypropylene triblock copolymers) by weight of theformulation. In some of such embodiments, the compositions contain lessthan 2% of the extended release components (e.g., gelling componentssuch as polyoxyethylene-polyoxypropylene triblock copolymers) by weightof the formulation. In some of such embodiments, the compositionscontain less than 1% of the extended release components (e.g., gellingcomponents such as polyoxyethylene-polyoxypropylene triblock copolymers)by weight of the formulation. In some of such embodiments, a compositiondescribed herein that is used for perfusion of a surgical area containssubstantially no gelling component and is an immediate releasecomposition.

In certain embodiments, a composition described herein is administeredbefore an otic intervention (e.g., before implantation of a medicaldevice or a cell-based therapeutic). In certain embodiments, acomposition described herein is administered during an otic intervention(e.g., during implantation of a medical device or a cell-basedtherapeutic). In other embodiments, a composition described herein isadministered after an otic intervention (e.g., after implantation of amedical device or a cell-based therapeutic). In some of suchembodiments, a composition described herein that is administered afterthe otic intervention is an intermediate release or extended releasecomposition (e.g., a composition comprising an antibiotic, a compositioncomprising an anti-inflammatory agent, a composition comprising a anantibiotic and an anti-inflammatory agent or the like) and containsgelling components as described herein. In some embodiments, an implant(e.g., a tympanostomy tube) is coated with a composition or devicedescribed herein prior to insertion in the ear.

Dosing Methods and Schedules

Drugs delivered to the middle or inner ear have been administeredsystemically via oral, intravenous or intramuscular routes. However,systemic administration for pathologies local to the middle or inner earincreases the likelihood of systemic toxicities and adverse side effectsand creates a non-productive distribution of drug in which high levelsof drug are found in the serum and correspondingly lower levels arefound at the middle or inner ear.

Intratympanic injection of therapeutic agents is the technique ofinjecting a therapeutic agent behind the tympanic membrane into themiddle and/or inner ear. In one embodiment, the formulations describedherein are administered directly into the tympanic cavity viatranstympanic injection. In another embodiment, the auris-acceptableciprofloxacin formulations described herein are administered onto thetympanic cavity via a non-transtympanic approach to the middle or innerear.

In one embodiment the delivery system is a syringe and needle apparatusthat is capable of piercing the tympanic membrane and directly accessingthe tympanic cavity. In some embodiments, the needle on the syringe iswider than an 18 gauge needle. In another embodiment, the needle gaugeis from 18 gauge to 31 gauge. In a further embodiment, the needle gaugeis from 25 gauge to 30 gauge. Depending upon the thickness or viscosityof the ciprofloxacin compositions or formulations, the gauge level ofthe syringe or hypodermic needle may be varied accordingly. In anotherembodiment, the internal diameter of the needle can be increased byreducing the wall thickness of the needle (commonly referred as thinwall or extra thin wall needles) to reduce the possibility of needleclogging while maintaining an adequate needle gauge.

In another embodiment, the needle is a hypodermic needle used forinstant delivery of the gel formulation. The hypodermic needle may be asingle use needle or a disposable needle. In some embodiments, a syringemay be used for delivery of the pharmaceutically acceptable gel-basedciprofloxacin-containing compositions as disclosed herein wherein thesyringe has a press-fit (Luer) or twist-on (Luer-lock) fitting. In oneembodiment, the syringe is a hypodermic syringe. In another embodiment,the syringe is made of plastic or glass. In yet another embodiment, thehypodermic syringe is a single use syringe. In a further embodiment, theglass syringe is capable of being sterilized. In yet a furtherembodiment, the sterilization occurs through an autoclave. In anotherembodiment, the syringe comprises a cylindrical syringe body wherein thegel formulation is stored before use. In other embodiments, the syringecomprises a cylindrical syringe body wherein the pharmaceuticallyacceptable gel-based ciprofloxacin compositions as disclosed herein isstored before use which conveniently allows for mixing with a suitablepharmaceutically acceptable buffer. In other embodiments, the syringemay contain other excipients, stabilizers, suspending agents, diluentsor a combination thereof to stabilize or otherwise stably store theciprofloxacin or other pharmaceutical compounds contained therein.

In some embodiments, the syringe comprises a cylindrical syringe bodywherein the body is compartmentalized in that each compartment is ableto store at least one component of the auris-acceptable ciprofloxacingel formulation. In a further embodiment, the syringe having acompartmentalized body allows for mixing of the components prior toinjection into the auris media or auris interna. In other embodiments,the delivery system comprises multiple syringes, each syringe of themultiple syringes contains at least one component of the gel formulationsuch that each component is pre-mixed prior to injection or is mixedsubsequent to injection. In a further embodiment, the syringes disclosedherein comprise at least one reservoir wherein the at least onereservoir comprises ciprofloxacin, or a pharmaceutically acceptablebuffer, or a viscosity enhancing agent, such as a gelling agent or acombination thereof. Commercially available injection devices areoptionally employed in their simplest form as ready-to-use plasticsyringes with a syringe barrel, needle assembly with a needle, plungerwith a plunger rod, and holding flange, to perform an intratympanicinjection.

In some embodiments, the delivery device is an apparatus designed foradministration of therapeutic agents to the middle and/or inner ear. Byway of example only: GYRUS Medical Gmbh offers micro-otoscopes forvisualization of and drug delivery to the round window niche; Arenberghas described a medical treatment device to deliver fluids to inner earstructures in U.S. Pat. Nos. 5,421,818; 5,474,529; and 5,476,446, eachof which is incorporated by reference herein for such disclosure. U.S.patent application Ser. No. 08/874,208, which is incorporated herein byreference for such disclosure, describes a surgical method forimplanting a fluid transfer conduit to deliver therapeutic agents to theinner ear. U.S. Patent Application Publication 2007/0167918, which isincorporated herein by reference for such disclosure, further describesa combined otic aspirator and medication dispenser for intratympanicfluid sampling and medicament application.

The auris-acceptable compositions or formulations containingciprofloxacin described herein are administered for prophylactic and/ortherapeutic treatments. In therapeutic applications, the ciprofloxacincompositions are administered to a patient already suffering from anautoimmune disease, condition or disorder, in an amount sufficient tocure or at least partially arrest the symptoms of the disease, disorderor condition. Amounts effective for this use will depend on the severityand course of the disease, disorder or condition, previous therapy, thepatient's health status and response to the drugs, and the judgment ofthe treating physician.

Frequency of Administration

In some embodiments, a composition disclosed herein is administered toan individual in need thereof once. In some embodiments, a compositiondisclosed herein is administered to an individual in need thereof morethan once. In some embodiments, a first administration of a compositiondisclosed herein is followed by a second administration of a compositiondisclosed herein. In some embodiments, a first administration of acomposition disclosed herein is followed by a second and thirdadministration of a composition disclosed herein. In some embodiments, afirst administration of a composition disclosed herein is followed by asecond, third, and fourth administration of a composition disclosedherein. In some embodiments, a first administration of a compositiondisclosed herein is followed by a second, third, fourth, and fifthadministration of a composition disclosed herein. In some embodiments, afirst administration of a composition disclosed herein is followed by adrug holiday.

The number of times a composition is administered to an individual inneed thereof depends on the discretion of a medical professional, thedisorder, the severity of the disorder, and the individual's response tothe formulation. In some embodiments, a composition disclosed herein isadministered once to an individual in need thereof with a mild acutecondition. In some embodiments, a composition disclosed herein isadministered more than once to an individual in need thereof with amoderate or severe acute condition. In the case wherein the patient'scondition does not improve, upon the doctor's discretion theadministration of ciprofloxacin may be administered chronically, thatis, for an extended period of time, including throughout the duration ofthe patient's life in order to ameliorate or otherwise control or limitthe symptoms of the patient's disease or condition.

In the case wherein the patient's condition does not improve, upon thedoctor's discretion the administration of ciprofloxacin may beadministered chronically, that is, for an extended period of time,including throughout the duration of the patient's life in order toameliorate or otherwise control or limit the symptoms of the patient'sdisease or condition.

In the case wherein the patient's status does improve, upon the doctor'sdiscretion the administration of ciprofloxacin may be givencontinuously; alternatively, the dose of drug being administered may betemporarily reduced or temporarily suspended for a certain length oftime (i.e., a “drug holiday”). The length of the drug holiday variesbetween 2 days and 1 year, including by way of example only, 2 days, 3days, 4 days, 5 days, 6 days, 7 days, 10 days, 12 days, 15 days, 20days, 28 days, 35 days, 50 days, 70 days, 100 days, 120 days, 150 days,180 days, 200 days, 250 days, 280 days, 300 days, 320 days, 350 days,and 365 days. The dose reduction during a drug holiday may be from10%-100%, including by way of example only 10%, 15%, 20%, 25%, 30%, 35%,40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, and 100%.

Once improvement of the patient's otic conditions has occurred, amaintenance ciprofloxacin dose is administered if necessary.Subsequently, the dosage or the frequency of administration, or both, isoptionally reduced, as a function of the symptoms, to a level at whichthe improved disease, disorder or condition is retained. In certainembodiments, patients require intermittent treatment on a long-termbasis upon any recurrence of symptoms.

The amount of ciprofloxacin that will correspond to such an amount willvary depending upon factors such as the particular compound, diseasecondition and its severity, according to the particular circumstancessurrounding the case, including, e.g., the route of administration, theautoimmune condition being treated, the target area being treated, andthe subject or host being treated. In general, however, doses employedfor adult human treatment will typically be in the range of 0.02-50 mgper administration, preferably 1-15 mg per administration. The desireddose is presented in a single dose or as divided doses administeredsimultaneously (or over a short period of time) or at appropriateintervals.

Pharmacokinetics of Otic Formulations

In one embodiment, the formulations disclosed herein additionallyprovides an immediate release of ciprofloxacin from the composition, orwithin 1 minute, or within 5 minutes, or within 10 minutes, or within 15minutes, or within 30 minutes, or within 60 minutes or within 90minutes. In other embodiments, a therapeutically effective amount ofciprofloxacin is released from the composition immediately, or within 1minute, or within 5 minutes, or within 10 minutes, or within 15 minutes,or within 30 minutes, or within 60 minutes or within 90 minutes. Incertain embodiments the composition comprises an auris-pharmaceuticallyacceptable gel formulation providing immediate release of ciprofloxacin.Additional embodiments of the formulation may also include an agent thatenhances the viscosity of the formulations included herein.

In other or further embodiments, the formulation provides an extendedrelease formulation ciprofloxacin. In certain embodiments, diffusion ofciprofloxacin from the formulation occurs for a time period exceeding 5minutes, or 15 minutes, or 30 minutes, or 1 hour, or 4 hours, or 6hours, or 12 hours, or 18 hours, or 1 day, or 2 days, or 3 days, or 4days, or 5 days, or 6 days, or 7 days, or 10 days, or 12 days, or 14days, or 18 days, or 21 days, or 25 days, or 30 days, or 45 days, or 2months or 3 months or 4 months or 5 months or 6 months or 9 months or 1year. In other embodiments, a therapeutically effective amount ofciprofloxacin is released from the formulation for a time periodexceeding 5 minutes, or 15 minutes, or 30 minutes, or 1 hour, or 4hours, or 6 hours, or 12 hours, or 18 hours, or 1 day, or 2 days, or 3days, or 4 days, or 5 days, or 6 days, or 7 days, or 10 days, or 12days, or 14 days, or 18 days, or 21 days, or 25 days, or 30 days, or 45days, or 2 months or 3 months or 4 months or 5 months or 6 months or 9months or 1 year.

In other embodiments, the formulation provides both an immediate releaseand an extended release formulation of ciprofloxacin. In yet otherembodiments, the formulation contains a 0.25:1 ratio, or a 0.5:1 ratio,or a 1:1 ratio, or a 1:2 ratio, or a 1:3, or a 1:4 ratio, or a 1:5ratio, or a 1:7 ratio, or a 1:10 ratio, or a 1:15 ratio, or a 1:20 ratioof immediate release and extended release formulations. In a furtherembodiment the formulation provides an immediate release of a firstciprofloxacin and an extended release of a second ciprofloxacin or othertherapeutic agent. In yet other embodiments, the formulation provides animmediate release and extended release formulation of ciprofloxacin, andat least one therapeutic agent. In some embodiments, the formulationprovides a 0.25:1 ratio, or a 0.5:1 ratio, or a 1:1 ratio, or a 1:2ratio, or a 1:3, or a 1:4 ratio, or a 1:5 ratio, or a 1:7 ratio, or a1:10 ratio, or a 1:15 ratio, or a 1:20 ratio of immediate release andextended release formulations of a first ciprofloxacin and secondtherapeutic agent, respectively.

In a specific embodiment the formulation provides a therapeuticallyeffective amount of ciprofloxacin at the site of disease withessentially no systemic exposure. In an additional embodiment theformulation provides a therapeutically effective amount of ciprofloxacinat the site of disease with essentially no detectable systemic exposure.In other embodiments, the formulation provides a therapeuticallyeffective amount of ciprofloxacin at the site of disease with little orno detectable systemic exposure.

The combination of immediate release, delayed release and/or extendedrelease ciprofloxacin compositions or formulations may be combined withother pharmaceutical agents, as well as the excipients, diluents,stabilizers, tonicity agents and other components disclosed herein. Assuch, depending upon the thickness or viscosity desired, or the mode ofdelivery chosen, alternative aspects of the embodiments disclosed hereinare combined with the immediate release, delayed release and/or extendedrelease embodiments accordingly.

In certain embodiments, the pharmacokinetics of the ciprofloxacinformulations described herein are determined by intratympanic injectionof the formulation into the test animal (including by way of example, aguinea pig or a chinchilla). At a determined period of time (e.g., 6hours, 12 hours, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, and 7days for testing the pharmacokinetics of a formulation over a 1 weekperiod), the test animal is euthanized and the level of ciprofloxacin inthe ear is measured. In addition, the systemic level of ciprofloxacin ismeasured by withdrawing a blood sample from the test animal. In order todetermine whether the formulation impedes hearing, the hearing of thetest animal is optionally tested.

FIG. 5 shows predicted tunable release of an active agent from fourcompositions.

Kits/Articles of Manufacture

The disclosure also provides kits for preventing, treating orameliorating the symptoms of a disease or disorder in a mammal. Suchkits generally will comprise one or more of controlled-releaseciprofloxacin compositions or devices disclosed herein, and instructionsfor using the kit. The disclosure also contemplates the use of one ormore of controlled-release ciprofloxacin compositions, in themanufacture of medicaments for treating, abating, reducing, orameliorating the symptoms of a disease, dysfunction, or disorder in amammal, such as a human that has, is suspected of having, or at risk fordeveloping an ear disorder.

In some embodiments, kits include a carrier, package, or container thatis compartmentalized to receive one or more containers such as vials,tubes, and the like, each of the container(s) including one of theseparate elements to be used in a method described herein. Suitablecontainers include, for example, bottles, vials, syringes, and testtubes. In other embodiments, the containers are formed from a variety ofmaterials such as glass or plastic.

The articles of manufacture provided herein contain packaging materials.Packaging materials for use in packaging pharmaceutical products arealso presented herein. See, e.g., U.S. Pat. Nos. 5,323,907, 5,052,558and 5,033,252. Examples of pharmaceutical packaging materials include,but are not limited to, blister packs, bottles, tubes, inhalers, pumps,bags, vials, containers, syringes, bottles, and any packaging materialsuitable for a selected formulation and intended mode of administrationand treatment. A wide array of ciprofloxacin formulations compositionsprovided herein are contemplated as are a variety of treatments for anydisease, disorder, or condition that would benefit by controlled releaseadministration of ciprofloxacin to the ear.

In some embodiments, a kit includes one or more additional containers,each with one or more of various materials (such as reagents, optionallyin concentrated form, and/or devices) desirable from a commercial anduser standpoint for use of a formulation described herein. Non-limitingexamples of such materials include, but not limited to, buffers,diluents, filters, needles, syringes; carrier, package, container, vialand/or tube labels listing contents and/or instructions for use andpackage inserts with instructions for use. A set of instructions isoptionally included. In a further embodiment, a label is on orassociated with the container. In yet a further embodiment, a label ison a container when letters, numbers or other characters forming thelabel are attached, molded or etched into the container itself; a labelis associated with a container when it is present within a receptacle orcarrier that also holds the container, e.g., as a package insert. Inother embodiments a label is used to indicate that the contents are tobe used for a specific therapeutic application. In yet anotherembodiment, a label also indicates directions for use of the contents,such as in the methods described herein.

In certain embodiments, the pharmaceutical compositions are presented ina pack or dispenser device which contains one or more unit dosage formscontaining a compound provided herein. In another embodiment, the packfor example contains metal or plastic foil, such as a blister pack. In afurther embodiment, the pack or dispenser device is accompanied byinstructions for administration. In yet a further embodiment, the packor dispenser is also accompanied with a notice associated with thecontainer in form prescribed by a governmental agency regulating themanufacture, use, or sale of pharmaceuticals, which notice is reflectiveof approval by the agency of the form of the drug for human orveterinary administration. In another embodiment, such notice, forexample, is the labeling approved by the U.S. Food and DrugAdministration for prescription drugs, or the approved product insert.In yet another embodiment, compositions containing a compound providedherein formulated in a compatible pharmaceutical carrier are alsoprepared, placed in an appropriate container, and labeled for treatmentof an indicated condition

Aseptic Container

In one refinement of the method, the aseptic container is sealed with acap.

In one refinement of the method, the cap comprises a metal frame havinga top wall and a side wall.

In one refinement of the method, the metal frame is made of aluminum.

In one refinement of the method, the cap further comprises a septumsecured against the aseptic container by the aluminum frame.

In one refinement of the method, the method further comprises the stepof storing of the aseptic container containing the sterilizedformulation below room temperature prior to step (1).

In one refinement of the method, the method further comprises the stepof storing of the aseptic container containing the sterilizedformulation at from about 36° F. to about 46° F. prior to step (1).

In one refinement of the method, the aseptic container containing thesterilized formulation is stored away from light prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation for at least 5 seconds prior to step (1).

In one refinement of the method, the method further comprises the stepof shaking of the aseptic container containing the sterilizedformulation by holding the cap of the aseptic container prior toadministration.

Syringe

In some embodiment, the kit comprises a 0.5 mL synringe, 1.0 mL syringe,1.5 mL syringe, or 2.0 mL syringe. In some embodiments, the kit comprisea 1.0 mL syringe.

In one refinement of the method, about 0.3 mL of the sterilizedformulation is transferred from the aseptic container to the syringe byusing the preparation needle in step (1) of the method of preparing andadministrating the sterilized formulation described earlier.

In one refinement of the method, the method further comprises the stepof priming the syringe between step (2) and step (3) of the method ofpreparing and administrating the sterilized formulation describedearlier.

In one refinement of the method, the priming leave about 0.1 mLinjectable volume of the sterilized formulation in the syringe.

Needle

In one refinement of the method, the administration needle is from 20gauge to 24 gauge.

In one refinement of the method, the administration needle is flexible.

In one refinement of the method, the administration needle has a blunttip.

In one refinement of the method, the administration needle isconnectable to the syringe through luer lock.

In one refinement of the method, the administration needle has a lengthof from about 2 inches to about 3 inches.

In one refinement of the method, the preparation needle is from 18 gaugeto 21 gauge.

In one refinement of the method, the preparation needle is rigid.

In one refinement of the method, the preparation needle has a sharp tip.

In one refinement of the method, the preparation needle is connectableto the syringe through luer lock.

Non-Straight Administration Needle

In some embodiments of the otic product kit or method of preparing andadministrating a sterilized formulation disclosed herein, theadministration needle is not straight, as shown in FIG. 6.

In some embodiments, the administration needle comprises at least onebend along longitudinal axis.

In some embodiments, the administration needle has one bend at aproximal portion of the administration needle.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of more than 90 degrees and lessthan 180 degrees.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of 100-170 degrees, 110-170degrees, 120-170 degrees, 130-170 degrees, or 140-160 degrees.

In some embodiments, the the bend at a proximal portion of theadministration needle forms an angles of 100-110 degrees, 110-120degrees, 120-130 degrees, 130-140 degrees, or 140-150 degrees, 150-160degrees, or 160-170 degrees.

In some embodiments, the administration needle comprises at least onecurved portions along longitudinal axis.

In some embodiments, the combination of geometric configuration of theneedles, in combination with one or more other technical features of thepresent disclosure, provides additional desirable or beneficialcharacteristics to the otic product kit or method of preparing andadministrating a sterilized formulation disclosed herein, including butnot limited to, convenience of administration, location of delivery,maneuverability around otic anatomy, etc.

Some non-limiting embodiments contemplated in the present disclosure arelisted below.

1. An otic product kit for administration of a sterlized formulation,comprising:

an aseptic container containing the sterilized formulation;

a syring; and

an administration needle connectable to the syringe, wherein thesterilized formulation comprising: from about 5.5 wt % to about 6.5 wt %multiparticulate ciprofloxacin; from about 15 wt % to about 17 wt %poloxamer 407; and water.

2. The otic product kit of Embodiment 1, wherein the aseptic containeris sealed with a cap.3. The otic product kit of Embodiment 2, wherein the cap comprises ametal frame having a top wall and a side wall.4. The otic product kit of Embodiment 3, wherein the metal frame is madeof aluminum.5. The otic product kit of Embodiment 3 or 4, wherein the cap furthercomprises a septum secured against the aseptic container by the aluminumframe.6. The otic product kit of any one of Embodiments 1-5, wherein theadministration needle is from 20 gauge to 24 gauge.7. The otic product kit of any one of Embodiments 1-6, wherein theadministration needle is flexible.8. The otic product kit of any one of Embodiments 1-7, wherein theadministration needle has a blunt tip.9. The otic product kit of any one of Embodiments 1-8, wherein theadministration needle is connectable to the syringe through luer lock.10. The otic product kit of any one of Embodiments 1-8, wherein theadministration needle has a length of from about 2 inches to about 3inches.11. The otic product kit of any one of Embodiments 1-10, furthercomprising a preparation needle for transferring the sterilized oticformulation from the aseptic container to the syringe.12. The otic product kit of Embodiment 11, wherein the preparationneedle is from 18 gauge to 21 gauge.13. The otic product kit of any one of Embodiments 11-12, wherein thepreparation needle is rigid.14. The otic product kit of any one of Embodiments 11-13, wherein thepreparation needle has a sharp tip.15. The otic product kit of any one of Embodiments 11-14, wherein thepreparation needle is connectable to the syringe through luer lock.16. The otic product kit of any one of Embodiments 1-15, furthercomprising an alcohol swab.17. The otic product kit of any one of Embodiments 1-16, furthercomprising an ice pack.18. The otic product kit of any one of Embodiments 1-17, furthercomprising a drape.19. The otic product kit of any one of Embodiments 1-18, furthercomprising a duplicate of each component for bilateral administration.20. The otic product kit of any one of Embodiments 1-19, furthercomprising an instruction for using the otic product kit.21. The otic product kit of Embodiment 20, wherein the instructioncomprises storing of the aseptic container containing the sterilizedformulation below room temperature prior to administration.22. The otic product kit of Embodiment 20, wherein the instructioncomprises storing of the aseptic container containing the sterilizedformulation at from about 36° F. to about 46° F. prior toadministration.23. The otic product kit of any one of Embodiments 20-22, wherein theinstruction comprises storing of the aseptic container containing thesterilized formulation away from light prior to administration.24. The otic product kit of any one of Embodiments 20-23, wherein theinstruction further comprises shaking of the aseptic containercontaining the sterilized formulation prior to administration.25. The otic product kit of Embodiment 24, wherein the instructionfurther comprises shaking of the aseptic container containing thesterilized formulation for at least 5 seconds prior to administration.26. The otic product kit of Embodiment 24 or 25, wherein the instructionfurther comprises shaking of the aseptic container containing thesterilized formulation by holding the cap of the aseptic container priorto administration.27. The otic product kit of any one of Embodiments 20-26, wherein theinstruction further comprises transferring the sterilized formulationfrom the aseptic container to the syringe prior to administration.28. The otic product kit of Embodiment 27, wherein the instructionfurther comprises transferring the sterilized formulation from theaseptic container to the syringe by using the preparation needle priorto administration.29. The otic product kit of Embodiment 28, wherein the instructionfurther comprises transferring about 0.3 mL of the sterilizedformulation from the aseptic container to the syringe by using thepreparation needle prior to administration.30. The otic product kit of any one of Embodiments 20-29, wherein theinstruction further comprises replacing the preparation needle with theadministration needle and priming the syringe after the sterilizedformulation from the aseptic container to the syringe.31. The otic product kit of Embodiment 30, wherein the priming leaveabout 0.1 mL injectable volume of the sterilized formulation in thesyringe to be injected through the administration needled.32. The otic product kit of any one of Embodiments 20-31, wherein theinstruction further comprises repeating previous steps to prepare asecond syringe for bilateral administration.33. The otic product kit of any one of Embodiments 20-32, wherein theinstruction further comprises injecting the the sterilized formulationfrom the syringe through the administration needle into the ear of apatient.34. The otic product kit of any one of Embodiments 1-33, wherein themultiparticulate ciprofloxacin has a D90 of from about 5 μm to about 40μm.35. The otic product kit of any one of Embodiments 1-34, wherein thesterilized formulation provides sustained release of a therapeuticallyeffective amount of ciprofloxacin into the ear for a period of at least5 days after a single administration.36. The otic product kit of any one of Embodiments 1-35, where thesterilized formulation has a pH of from about 7.0 to about 8.0.37. The otic product kit of any one of Embodiments 1-35, where thesterilized formulation has an osmolarity of from about 270 mOsm/L toabout 320 mOsm/L.38. A method of preparing and administrating a sterilized formulationcomprising from about 5.5 wt % to about 6.5 wt % multiparticulateciprofloxacin, from about 15 wt % to about 17 wt % poloxamer 407, andwater, the method comprising:

-   -   (1) transferring the sterilized otic formulation from an aseptic        container to a syringe through a preparation needle;    -   (2) replacing the preparation needle with an administration        needle; and    -   (3) injecting the sterilized otic formulation from the syringe        through the administration needle into the ear of a patient.        39. The method of Embodiment 38, wherein the aseptic container        is sealed with a cap.        40. The method of Embodiment 39, wherein the cap comprises a        metal frame having a top wall and a side wall.        41. The method of Embodiment 40, wherein the metal frame is made        of aluminum.        42. The method of Embodiment 40 or 41, wherein the cap further        comprises a septum secured against the aseptic container by the        aluminum frame.        43. The method of any one of Embodiments 38-42, wherein the        administration needle is from 20 gauge to 24 gauge.        44. The method of any one of Embodiments 38-43, wherein the        administration needle is flexible.        45. The method of any one of Embodiments 38-44, wherein the        administration needle has a blunt tip.        46. The method of any one of Embodiments 38-45, wherein the        administration needle is connectable to the syringe through luer        lock.        47. The method of any one of Embodiments 38-46, wherein the        administration needle has a length of from about 2 inches to        about 3 inches.        48. The method of any one of Embodiments 38-47, further        comprising a preparation needle for transferring the sterilized        otic formulation from the aseptic container to the syringe.        49. The method of Embodiment 48, wherein the preparation needle        is from 18 gauge to 21 gauge.        50. The method of any one of Embodiments 48-49, wherein the        preparation needle is rigid.        51. The method of any one of Embodiments 48-50, wherein the        preparation needle has a sharp tip.        52. The method of any one of Embodiments 48-51, wherein the        preparation needle is connectable to the syringe through luer        lock.        53. The method Embodiments 38-51, further comprising the step of        storing of the aseptic container containing the sterilized        formulation below room temperature prior to step (1).        54. The method Embodiment 38, further comprising the step of        storing of the aseptic container containing the sterilized        formulation at from about 36° F. to about 46° F. prior to step        (1).        55. The method of Embodiment 54, wherein the the aseptic        container containing the sterilized formulation is stored away        from light prior to step (1).        56. The method of any one of Embodiments 38-55, further        comprising the step of shaking of the aseptic container        containing the sterilized formulation prior to step (1).        57. The method of any one of Embodiments 38-55, further        comprises the step of shaking of the aseptic container        containing the sterilized formulation for at least 5 seconds        prior to step (1).        58. The method of Embodiment 56 or 57, further comprises the        step of shaking of the aseptic container containing the        sterilized formulation by holding the cap of the aseptic        container prior to administration.        59. The method of any one of Embodiments 38-58, wherein about        0.3 mL of the sterilized formulation is transferred from the        aseptic container to the syringe by using the preparation needle        in step (1).        60. The method of any one of Embodiments 38-59, further        comprising the step of priming the syringe between step (2) and        step (3).        61. The method of Embodiment 60, wherein the priming leave about        0.1 mL injectable volume of the sterilized formulation in the        syringe.        62. The method of any one of Embodiments 38-61, further        comprising repeating each step for bilateral administration.        63. The otic product kit of any one of Embodiments 1-37, wherein        the administration needle is not straight.        64. The otic product kit of Embodiment 63, wherein the        administration needle comprises at least one bend along        longitudinal axis.        65. The otic product kit of Embodiment 64, wherein the        administration needle has one bend at a proximal portion of the        administration needle.        66. The otic product kit of Embodiment 65, wherein the the bend        at a proximal portion of the administration needle forms an        angles of more than 90 degrees and less than 180 degrees.        67. The otic product kit of Embodiment 66, wherein the the bend        at a proximal portion of the administration needle forms an        angles of 100-170 degrees, 110-170 degrees, 120-170 degrees,        130-170 degrees, or 140-160 degrees.        68. The otic product kit of Embodiment 66, wherein the the bend        at a proximal portion of the administration needle forms an        angles of 100-110 degrees, 110-120 degrees, 120-130 degrees,        130-140 degrees, or 140-150 degrees, 150-160 degrees, or 160-170        degrees.        69. The otic product kit of Embodiment 63, wherein the        administration needle comprises at least one curved portions        along longitudinal axis.        70. The method of any one of Embodiments 38-62, wherein the        administration needle is not straight.        71. The otic product kit of Embodiment 70, wherein the        administration needle comprises at least one bend along        longitudinal axis.        72. The otic product kit of Embodiment 71, wherein the        administration needle has one bend at a proximal portion of the        administration needle.        73. The otic product kit of Embodiment 72, wherein the the bend        at a proximal portion of the administration needle forms an        angles of more than 90 degrees and less than 180 degrees.        74. The otic product kit of Embodiment 73, wherein the the bend        at a proximal portion of the administration needle forms an        angles of 100-170 degrees, 110-170 degrees, 120-170 degrees,        130-170 degrees, or 140-160 degrees.        75. The otic product kit of Embodiment 73, wherein the the bend        at a proxinal portion of the administration needle forms an        angles of 100-110 degrees, 110-120 degrees, 120-130 degrees,        130-140 degrees, or 140-150 degrees, 150-160 degrees, or 160-170        degrees.        76. The otic product kit of Embodiment 70, wherein the        administration needle comprises at least one curved portions        along longitudinal axis.

EXAMPLES Example 1—Form (Anhydrous/Hydrate) of Ciprofloxacin—Loss onDrying

To assess the form of ciprofloxacin samples described in the presentdisclosure, a comparison experiment is conducted to evaluate thesample's loss of weight upon heating. Loss of less than 2% in weightgenerally indicates that the sample is in anhydrous form. On the otherhand, loss of more than 10% in weight generally indicates that thesample is in hydrate form. The conditions and results of the experimentare summarized below:

Experimental Setup—Loss on Drying:

-   -   If suspension: Pipette Cipro suspension onto filter on vacuum        filter flask    -   Transfer filter/dry powder to 40° C. oven, hold 24 hours    -   Transfer solid to pre-weighed aluminum pan and weigh solid    -   Transfer pan to 125° C. oven, hold one hour    -   Weigh again and determine weight loss due to 125° C.

TABLE 1 Form (Anhydrous/Hydrate) of Ciprofloxacin - Loss on DryingSample Weight Loss No. Sample Description on Drying 1 Cipro anhydrous(dry powder; no suspension) 0.1% 2 Cipro hydrate (dry powder; nosuspension) 11.1% 3 Cipro suspension (5° C. addition of Cipro 13.7%anhydrous powder to water, homogenized) 4 Cipro suspension (135° C.autoclave of Sample 1.0% 3; hot suspension) 5 Cipro suspension (135° C.autoclave of Sample 15.9% 3; cooled down suspension)

The first entry indicates that ciprofloxacin anhydrous losses less than1% weigh upon oven heating. The second entry indicates thatciprofloxacin hydrate losses more than 10% weigh upon oven heating. Thethird entry indicates that ciprofloxacin anhydrous is converted intohydrate form upon mixing with water (as the solid isolated from themixture losses more than 10% weigh upon oven hearing). The fourth entryindicates that that the ciprofloxacin hydrate suspension in third entry,upon heating at high temperature, reverts back to anhydrous form in thehot suspension. Finally, the last entry indicates that ciprofloxacin inthe hot suspension heated at high temperature is re-hydrated duringcool-down. Without wishing to be bound by any particular theory, it iscontemplated that the hydrate-anhydrous-hydrate transformationcontributes to the solidification of the ciprofloxacin suspensiondescribed herein.

Example 2—Form (Anhydrous/Hydrate) of Ciprofloxacin—X-RayCharacterization

FIG. 1 shows X-ray characterization of ciprofloxacin anhydrous (bottom),ciprofloxacin hydrate (middle), and an aqueous ciprofloxacin suspensionformed according to the method disclosure herein (top). FIG. 2 showsX-ray characterization of an aqueous ciprofloxacin suspension after heatsterilization at 135° C. (without cooling down). In a non-limitingsterilization example, dry powder ciprofloxacin free base anhydrate withthe X-ray characterization at the bottom of FIG. 1 is used. When this isadded to water, it immediately hydrates. Notably, ciprofloxacin changesforms (showing increasing particle size and visually showing longneedles forming) and thickens (and can solidify) during this step. Thiscould be similar to the solidification during cool-down, suggesting thatthe conversion from anhydrate at high temperature back to hydrate at lowtemperature is involved in causing the solidification.

Referring now to FIG. 1, the X-ray characterization at the bottomrepresents ciprofloxacin anhydrous, and the X-ray characterization inthe middle represents ciprofloxacin hydrate. Referring now to FIG. 2,the X-ray characterization represents an aqueous ciprofloxacinsuspension after heat sterilization at 135° C. (without cooling down).Comparison of the X-ray characterization of those non-limiting examplesindicates the presence of ciprofloxacin in anhydrous form when anaqueous ciprofloxacin suspension is heated at high temperature (e.g.135° C.)

When this hot ciprofloxacin free base (anhydrous) suspension is cooleddown, it solidified. This solidified material is shown to be the hydrateform.

Referring again to FIG. 1, the X-ray characterization at the bottomrepresents ciprofloxacin anhydrous, and the X-ray characterization inthe middle represents ciprofloxacin hydrate. The X-ray characterizationat the top represents an aqueous ciprofloxacin suspension after heatsterilization at the lower temperature exposure (e.g. 100° C.-120° C.)after cooling down. Comparison of the X-ray characterization of thosenon-limiting examples indicates the presence of ciprofloxacin in hydrateform when an aqueous ciprofloxacin suspension is heated at the lowertemperature exposure (e.g. 100° C.-120° C.) after cooling down.

Example 3—Heat Sterilization of Ciprofloxacin

To demonstrate the features of the sterilization process describedherein, three manufacturing experiments are conducted by AllianceMedical Products (9342 Jeronimo Rd, Irvine, Calif. 92618), with resultssummarized below.

Engineering (Process Development) Manufacturing Run, Protocol 14047:105° C. exposure for 2 hours; no solidification of ciprofloxacinsuspension.

Engineering (Process Development) Manufacturing Run, Protocol 14047addendum 1: 115° C. exposure for 1 hour; no solidification ofciprofloxacin suspension.

Engineering (Process Development) Manufacturing Run, Protocol13156: >121.5° C. exposure for 20 minutes; ciprofloxacin suspensionsolidified.

Changes in the form during manufacturing process also results in changesin the particle size of ciprofloxacin API. Ciprofloxacin free baseanhydrous API powder has a typical particle size of D90 under 15 μm,upon conversion to the hydrate form, particle size increases to D90 ofaround 60 μm. The final drug product has particle size of D90 of about25 μm. Without wishing to be bound by any particular theory, one or morefeatures of the sterilization method described herein, including but notlimited to the use of a lower sterilization temperature and/orhomogenization of the suspension during the sterilization process, wouldcontribute to the particle size distribution of ciprofloxacin in thesuspension, and in the final product. In some embodiments, it is the useof a lower sterilization temperature and homogenization of thesuspension during the sterilization process that contributes to theparticle size distribution of ciprofloxacin in the suspension, and inthe final product.

Example 4—Filtration Sterilization of a Diluent Composition

The heat sterilized ciprofloxacin suspension could be further processedinto a ready-to-use drug product, such as by mixing with a diluentcomposition. In this example, the diluent composition is an aqueoussolution of a polyoxyethylene-polyoxypropylene copolymer (e.g. poloxamer407), a buffering agent (tromethamine), an osmolarity adjusting agent(e.g. sodium chloride), and a pH adjusting agent (hydrochloric acid)prepared as follows.

A concentrated poloxamer 407 buffered solution is prepared by mixing anddissolving all components with nitrogen sparging, under pressure, atapproximately 2-7° C. The poloxamer 407 buffered diluents composition issterile filtered through a 0.22 μm filter for further combination withthe ciprofloxacin suspension.

Example 5: Determination of Manufacturing Conditions for SterileFiltration

The temperature of the room is maintained below 25° C. to retain thetemperature of the solution at below 19° C. The temperature of thesolution is maintained at below 19° C. up to 3 hours of the initiationof the manufacturing, without the need to chill/cool the container.

Three different Sartoscale (Sartorius Stedim) filters with a surfacearea of 17.3 cm² are evaluated at 20 psi and 14° C. of solution

-   -   1) Sartopore 2, 0.2 μm 5445307HS-FF (PES), flow rate of 16        mL/min    -   2) Sartobran P, 0.2 μm 5235307HS-FF (cellulose ester), flow rate        of 12 mL/min    -   3) Sartopore 2 XLI, 0.2 μm 5445307IS-FF (PES), flow rate of 15        mL/min

Sartopore 2 filter 5441307H4-SS is used, filtration is carried out atthe solution temperature using a 0.45, 0.2 μm Sartopore 2 150 sterilecapsule (Sartorius Stedim) with a surface area of 0.015 m² at a pressureof 16 psi. Flow rate is measured at approximately 100 mL/min at 16 psi,with no change in flow rate while the temperature is maintained in the6.5-14° C. range. Decreasing pressure and increasing temperature of thesolution causes a decrease in flow rate due to an increase in theviscosity of the solution. Discoloration of the solution is monitoredduring the process.

TABLE 2 Predicted filtration time for a 17% poloxamer 407 diluentcomposition at a solution temperature range of 6.5-14° C. usingSartopore 2, 0.2 μm filters at a pressure of 16 psi of pressure SizeEstimated flow rate Time to filter 8 L Filter (m²) (mL/min) (estimated)Sartopore 2, size 4 0.015 100 mL/min 80 min Sartopore 2, size 7 0.05 330mL/min 24 min Sartopore 2, size 8 0.1 670 mL/min 12 min

Viscosity, Tgel and UV/Vis absorption is checked before filtrationevaluation. UV/Vis spectra are obtained by an Evolution 160 UV/Vis(Thermo Scientific). A peak in the range of 250-300 nm is attributed toBHT stabilizer present in the raw material (poloxamer). Table 3 listsphysicochemical properties of the above solutions before and afterfiltration.

TABLE 3 Physicochemical properties of 17% poloxamer 407 diluentcomposition before and after filtration Tgel Viscosity^(a) @ 19° C.Absorbance @ Sample (° C.) (cP) 274 nm Before filtration 22 100 0.3181After filtration 22 100 0.3081 ^(a)Viscosity measured at a shear rate of37.5 s⁻¹

The above process is applicable for manufacture of 17% P407formulations, and includes temperature analysis of the room conditions.Preferably, a maximum temperature of 19° C. reduces cost of cooling thecontainer during manufacturing. In some instances, a jacketed containeris used to further control the temperature of the solution to easemanufacturing concerns.

Example 6—Preparation of a Ready-to-Use Ciprofloxacin PoloxamerFormulation

In this non-limiting example, a ciprofloxacin suspension prepared as inExample 3 and a poloxamer 407 diluent are mixed together at asepticconditions to form a ready-to-use otic formulation that meets the highsterility requirements for intratympanic administered composition. Anexemplary formulation is provided below as a thermoreversible gel thatis an injectable liquid at room temperature and gels in the ear afterintratympanic delivery.

Quality Composition Composition Ingredient Standard Function (mg/mL)^(a)(mg/vial)^(b) Ciprofloxacin USP Active 60 210 ingredient Poloxamer 407NF Gel 157 549.5 formation Sodium USP Osmolality 4.5 15.75 Chloridemodifier Tromethamine USP Buffering 5.8 20.3 agent Hydrochloric NF pH QSfor pH QS for pH Acid adjustment adjustment adjustment (37.5% w/w) (pH7.0-8.0) (pH 7.0-8.0) Water for USP Vehicle QS to 1040 QS to 3640Injection (WFI) ^(a)Density of OTO-201 Drug Product containing 60 mg/mLciprofloxacin USP has been determined to be 1.04 g/mL. ^(b)Fill volumeis approximately 3.5 mL per vial.

The formulation has less than about 50 colony forming units (cfu) ofmicrobiological agents per gram of formulation, and has less than about5 endotoxin units (EU) per kg of body weight of a subject. Thecomposition is suitable for intratympanic administration.

Example 7—Preparation of a Ready-to-Use Vial Containing CiprofloxacinPoloxamer Formulation

The formulation in Example 6 is filled into an aseptic container (e.g. avial), stoppered, and capped, all under aseptic process conditions toform a ready-to-use medical/pharmaceutical product that meets thesterility requires for intratympanic administration. The formulation inthe vial has less than about 50 colony forming units (cfu) ofmicrobiological agents per gram of formulation, and has less than about5 endotoxin units (EU) per kg of body weight of a subject.

Example 8—In Vivo Testing of Intratympanic Injection of CiprofloxacinFormulation in a Guinea Pig

A cohort of 21 guinea pigs (Charles River, females weighing 200-300 g)is intratympanically injected with 50 μL of different P407-ciprofloxacinformulation prepared in Example 6 or Example 7. Animals are dosed onday 1. The release profile for the formulations is determined based onanalysis of the perilymph.

While preferred embodiments of the present invention have been shown anddescribed herein, such embodiments are provided by way of example only.Various alternatives to the embodiments described herein are optionallyemployed in practicing the inventions. It is intended that the followingclaims define the scope of the invention and that methods and structureswithin the scope of these claims and their equivalents be coveredthereby.

Example 9—a Product Label Describe a Product Kit and Method of UsingThereof

In this non-limiting example, a ciprofloxacin otic formulation preparedherein is incorporated into an otic product kit. Below is an exemplaryproduct label that describes the product kit and the method of usethereof.

Full Prescribing Information 1 Indications and Usage

OTIPRIO is indicated for the treatment of pediatric patients with otitismedia with middle ear effusion undergoing tympanostomy tube placement.

2 Dosage and Administration 2.1 Dosage

-   -   OTIPRIO is for intratympanic administration only.    -   _([AAO1])OTIPRIO is intended for single-patient use with two 0.1        mL doses available in each vial.    -   Administer OTIPRIO as a single intratympanic administration of        one 0.1 mL (6 mg) dose into each affected ear, following        suctioning of middle ear effusion.

2.2 Administration

Prior to preparation, vials can be placed on an ice pack covered with adrape to keep cold in order to minimize thickening.

During preparation, always hold the vial by the aluminum seal. IfOTIPRIO thickens during preparation, place the vial back inrefrigeration.

After preparation, syringes can be kept at room temperature or in therefrigerator prior to administration [see How Supplied/Storage andHandling (16)]. Keep syringes on their side.

Discard syringes if not administered in 3 hours.

Directions for OTIPRIO dose preparation is illustrated in FIG. 7.

3 Dosage Forms and Strengths

Otic Suspension: Each 1 mL of OTIPRIO contains a white,preservative-free, sterile otic suspension consisting of 6% (60 mg/mL)ciprofloxacin in a single-patient use glass vial.

4 Contraindications

OTIPRIO is contraindicated in patients with a history ofhypersensitivity to ciprofloxacin, to other quinolones, or to any of thecomponents of OTIPRIO.

5 Warnings and Precautions 5.1 Potential for Microbial Overgrowth

OTIPRIO may result in overgrowth of nonsusceptible bacteria and fungi.If such infections occur, institute alternative therapy.

6 Adverse Reactions

The following serious adverse reactions are described elsewhere in thelabeling:

-   -   Potential for Microbial Overgrowth [see Warnings and Precautions        (5.1]

6.1 Clinical Trials Experience

Because clinical studies are conducted under widely varying conditions,adverse reaction rates observed in the clinical studies of a drug cannotbe directly compared to rates in the clinical studies of another drugand may not reflect the rates observed in practice.

In two randomized, sham-controlled Phase 3 clinical studies,approximately 530 pediatric patients with otitis media with middle eareffusion undergoing tympanostomy tube placement were treated withOTIPRIO or sham administered intra-operatively as a single dose. Themedian age of the pediatric patients enrolled in the clinical trials was1.5 years; 62% of patients were 6 months through 2 years of age and 38%of patients were greater than 2 years of age.

Adverse reactions that occurred in at least 3% of OTIPRIO patients andat an incidence greater than sham are presented in Table 1.

TABLE 1 Adverse Reactions in Phase 3 Trials OTIPRIO Sham (N = 357) (N =173) Nasopharyngitis 5% 4% Irritability 5% 3% Rhinorrhea 3% 2%

8 Use in Specific Populations 8.1 Pregnancy Risk Summary

Animal reproduction studies have not been conducted with OTIPRIO. Noadequate and well-controlled studies have been performed in pregnantwomen. Because of the negligible systemic exposure associated withclinical administration of OTIPRIO, this product is expected to be ofminimal risk for maternal and fetal toxicity when administered topregnant women.

8.3 Nursing Mothers

Ciprofloxacin is excreted in human milk with systemic use. It is notknown whether ciprofloxacin is excreted in human milk followingintratympanic administration. Because many drugs are excreted in humanmilk, caution should be exercised when OTIPRIO is administered to anursing woman.

8.4 Pediatric Use

The safety and effectiveness of OTIPRIO in infants below six months ofage have not been established.

The safety and effectiveness of OTIPRIO was established in approximately532 pediatric patients with bilateral otitis media with middle eareffusion undergoing myringotomy with tympanostomy tube placement. Themedian age of patients enrolled in the clinical trials was 1.5 years;62% of patients were 6 months through 2 years of age and 38% of patientswere greater than 2 years of age [see Adverse Reactions (6.1) andClinical Studies (14)].

11 Description

OTIPRIO (ciprofloxacin otic suspension) 6% contains the syntheticquinolone antimicrobial, ciprofloxacin hydrochloride. OTIPRIO is forintratympanic administration. OTIPRIO is supplied as a white,preservative-free, sterile otic suspension of 6% (w/v) ciprofloxacin ina neutral pH, buffered, isotonic solution in a single-patient use glassvial with a rubber stopper containing 1 mL. The inactive ingredients arepoloxamer 407, sodium chloride, tromethamine, hydrochloric acid andwater for injection (WFI).

The thermosensitive suspension exists as a liquid at room temperature orbelow and gels when warmed [see How Supplied/Storage and Handling (16)].

Ciprofloxacin has the following nomenclature:

1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinolinecarboxylicacid. Its empirical formula is C₁₇H₁₈FN₃O₃ and its molecular weight is331.3.

Its chemical structure is as follows:

12 Clinical Pharmacology 12.1 Mechanism of Action

Ciprofloxacin is a quinolone antimicrobial [see 12.4Microbiology].

12.3 Pharmacokinetics

The plasma concentration of ciprofloxacin following bilateraladministration of 0.1 mL OTIPRIO was not measured.

12.4 Microbiology Mechanism of Action

The bactericidal action of ciprofloxacin results from interference withthe enzyme DNA gyrase, which is needed for the synthesis of bacterialDNA.

Resistance

Bacterial resistance to fluoroquinolones can develop throughchromosomally- or plasmid-mediated mechanisms. In vitro studiesdemonstrated cross-resistance between ciprofloxacin and somefluoroquinolones. There is generally no cross-resistance betweenciprofloxacin and other classes of antibacterial agents, such asbeta-lactams or aminoglycosides.

Antimicrobial Activity

Ciprofloxacin has been shown to be active against most isolates of thefollowing bacteria:

-   -   Gram-positive Bacteria        -   Staphylococcus aureus        -   Streptococcus pneumoniae    -   Gram-negative Bacteria        -   Haemophilus influenzae        -   Moraxella catarrhalis        -   Pseudomonas aeruginosa

13 Nonclinical Toxicology 13.1 Carcinogenesis, Mutagenesis, Impairmentof Fertility

Eight in vitro mutagenicity tests have been conducted withciprofloxacin, and the test results are listed below:

Salmonella/Microsome Test (Negative)

Escherichia coli DNA Repair Assay (Negative)

Mouse Lymphoma Cell Forward Mutation Assay (Positive)

Chinese Hamster V79 Cell HGPRT Test (Negative)

Syrian Hamster Embryo Cell Transformation Assay (Negative)

Saccharomyces cerevisiae Point Mutation Assay (Negative)

Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay(Negative)

Rat Hepatocyte DNA Repair Assay (Positive)

Thus, 2 of the 8 in vitro tests were positive, but results of thefollowing 3 in vivo test systems gave negative results:

Rat Hepatocyte DNA Repair Assay

Micronucleus Test (Mice)

Dominant Lethal Test (Mice)

Long-term carcinogenicity studies in mice and rats have been completedfor ciprofloxacin. After daily oral doses of 750 mg/kg in mice and 250mg/kg in rats (for mice and rats respectively, approximately 300 and 200times the maximum recommended clinical dose of ototopical ciprofloxacinbased upon body surface area, assuming total absorption of ciprofloxacinfrom the ear of a patient treated with OTIPRIO) were administered for upto 2 years, there was no evidence that ciprofloxacin had anycarcinogenic or tumorigenic effects in these species.

Fertility studies performed in rats at oral doses of ciprofloxacin up to100 mg/kg/day revealed no evidence of impairment. This would beapproximately 80 times the maximum recommended clinical dose ofototopical ciprofloxacin based upon body surface area, assuming totalabsorption of ciprofloxacin from the ear of a patient treated withOTIPRIO.

13.2 Animal Toxicology and/or Pharmacology

Guinea pigs dosed in the middle ear with OTIPRIO exhibited nodrug-related structural or functional changes of the cochlear haircells.

14 Clinical Studies

Two randomized, multicenter, controlled clinical trials in 532 pediatricpatients with bilateral otitis media with effusion undergoingmyringotomy with tympanostomy tube placement evaluated the safety andefficacy of OTIPRIO when administered intraoperatively as a single dose.The median age of patients enrolled in the clinical trials was 1.5years; 62% of patients were 6 months through 2 years of age and 38% ofpatients were greater than 2 years of age. The efficacy endpoint forboth trials was the cumulative proportion of study treatment failuresthrough Day 15, defined as the occurrence of any of the followingevents: otorrhea as determined by a blinded assessor, otic or systemicantibacterial drug use for any reason, as well as patients who missedvisits or were lost-to-follow-up.

Table 2 presents the results from each Phase 3 trial for the Intent toTreat and Per Protocol populations.

TABLE 2 Cumulative Proportion of Treatment Failures Through Day 15 inPhase 3 Trials Trial 1 (N = 266) Trial 2 (N = 266) % Difference %Difference (Sham − Otiprio) (Sham − Otiprio) Sham (95% confidence (95%confidence Population OTIPRIO |[HKM2] interval) OTIPRIO Sham interval)Intent to Treat^(a)) 25% 45% 20% 21% 45% 24% (44/179) (39/87) P11 (8%,32%)³ (38/178) (40/88) (12%, 36%)³ Per Protocol^(b)) 12% 39% 27% 17% 39%22% (18/148) (27/70) (14%, 39%)³ (27/159) (29/74) (10%, 35%)³^(a))Intent to Treat population: All randomized patients ^(b))PerProtocol population: Randomized patients compliant with the protocol;excludes patients with out of window/missed visits or lost to follow-up;this population represents 85% of the Intent to Treat population acrossboth Phase 3 trials ³P-value <0.001 for Cochran-Mantel-Haenszel test(adjusted for age-group)

Administration of OTIPRIO did not lead to impairment in hearingfunction, middle ear function or tube patency by Day 29.

16 How Supplied/Storage and Handling

OTIPRIO is a sterile, preservative-free, otic suspension of 6% (60mg/mL, w/v) ciprofloxacin in a neutral pH buffered, isotonic solutioncontaining a mucoadhesive glycol polymer, poloxamer 407.

Each OTIPRIO carton contains 1 mL of 6% (60 mg/mL, w/v) ciprofloxacin ina 2 mL single-patient use glass vial fitted with a rubber stopper.(NDC-69251-201-01)

OTIPRIO should be stored at 2 to 8° C. (36 to 46° F.) until prior to useto prevent thickening during preparation. Protect from light. Store inthe original carton until dose preparation.

We claim:
 1. An otic product kit for administration of a sterlizedformulation, comprising: an aseptic container containing the sterilizedformulation; a syring; and an administration needle connectable to thesyringe, wherein the sterilized formulation comprising: from about 5.5wt % to about 6.5 wt % multiparticulate ciprofloxacin; from about 15 wt% to about 17 wt % poloxamer 407; and water.
 2. The otic product kit ofclaim 1, wherein the aseptic container is sealed with a cap.
 3. The oticproduct kit of claim 2, wherein the cap comprises a metal frame having atop wall and a side wall.
 4. The otic product kit of claim 3, whereinthe metal frame is made of aluminum.
 5. The otic product kit of claim 4,wherein the cap further comprises a septum secured against the asepticcontainer by the aluminum frame.
 6. The otic product kit of claim 1,wherein the administration needle is from 20 gauge to 24 gauge.
 7. Theotic product kit of claim 1, wherein the administration needle isflexible.
 8. The otic product kit of claim 1, wherein the administrationneedle has a blunt tip.
 9. The otic product kit of claim 1, wherein theadministration needle has a length of from about 2 inches to about 3inches.
 10. The otic product kit of claim 1, further comprising apreparation needle for transferring the sterilized otic formulation fromthe aseptic container to the syringe.
 11. The otic product kit of claim10, wherein the preparation needle is from 18 gauge to 21 gauge.
 12. Theotic product kit of any one of claim 1, further comprising an alcoholswab.
 13. The otic product kit of any one of claim 1, further comprisingan ice pack.
 14. The otic product kit of any one of claim 1, furthercomprising a drape.
 15. The otic product kit of any one of claim 1,wherein the multiparticulate ciprofloxacin has a D90 of from about 5 μmto about 40 μm.
 16. The otic product kit of any one of claim 1, whereinthe sterilized formulation provides sustained release of atherapeutically effective amount of ciprofloxacin into the ear for aperiod of at least 5 days after a single administration.
 17. The oticproduct kit of any one of claim 1, where the sterilized formulation hasa pH of from about 7.0 to about 8.0.
 18. The otic product kit of any oneof claim 1, where the sterilized formulation has an osmolarity of fromabout 270 mOsm/L to about 320 mOsm/L.
 19. The otic product kit of claim1, wherein the administration needle is not straight.
 20. The oticproduct kit of claim 1, wherein the administration needle comprises atleast one bend along longitudinal axis.